Unlocking the Role of Occupational Therapy in Eating Disorder Recovery: A Deep Dive into ARFID and Anorexia Treatment Strategies

Join forces with me, Rajuta, and our insightful guest Jacqueline, a seasoned occupational therapy expert, as we navigate the complex interplay between occupational therapy and eating disorders. The conversation promises to equip listeners with a deeper understanding of how this therapeutic field helps individuals with ARFID and anorexia reclaim independence in their daily lives. Discover the transformative strategies occupational therapists employ, from sensory and oral motor work to fostering emotional resilience, all aimed at empowering those struggling with these intricate health challenges.

The episode unveils the often misunderstood Avoidant Restrictive Food Intake Disorder (ARFID) and its sensory food avoidance subtype, shedding light on its overlap with anorexia. Jacqueline's expertise shines as we discuss the nuanced role of exposure therapy in establishing healthier eating habits and setting individualized treatment goals. We confront the sensory issues that contribute to restrictive eating patterns, emphasizing repetition's crucial role in forming new, healthier eating behaviors. Embrace the knowledge shared as we dissect the sensory complexities and the tailored care required to support individuals on their road to recovery.

We wrap up with an earnest look at the psychosocial elements that are sometimes overshadowed in eating disorder treatment. The episode illuminates the need for a holistic, empathetic approach that addresses emotional health, spirituality, and social functioning. Moreover, the discussion traverses the significance of involving families in the therapeutic journey, highlighting how empathy, education, and collaborative efforts can fortify the support system essential for overcoming the challenges of eating disorders. Prepare to be part of a heartening dialogue that casts fresh perspectives on treating these disorders with understanding and specialized attention.

Transcript

Speaker 1: 0:02

Hi everyone. I'm Rajuta, host of Answer my Call. I'm a mental health therapist and owner of Mindful Group Practice, located in Pennsylvania. I work primarily with teenagers and women in my practice. I'm a mom to two teenagers, always waiting for them to answer my call. Welcome to the podcast, Jacqueline. I'm so excited to talk to you about the occupational therapy side to eating disorders and, because this is like a six-part series, I've been talking to so many different experts in the field who are coming from different approaches to eating disorders, especially because it's not really talked about. You know what are the different approaches, what are the different ways of thinking and interventions when it comes to eating disorders, so I'm super excited to have you on my podcast talking about the occupational therapy side of it, so welcome.

Speaker 2: 1:15

Thank you so much for having me on. I am so looking forward to this conversation. I think it is much needed and so important in the field of eating disorders.

Speaker 1: 1:25

Yeah, so could we start by sort of you explaining what an occupational therapist does in general and perhaps what the link is to eating disorders?

Speaker 2: 1:40

Sure. So with our discipline in occupational therapy, the overall goal is really to help individuals engage in meaningful activities as independently as possible. Which is so general that statement. But when you break down like meaningful activities it's really, you know, you think about the activities of daily living, so the activities that we engage in on a daily basis. So that could be oh my goodness, that could be anything to do with self-care or hygiene, you know, showering and getting out of bed in the morning and getting your morning coffee and your breakfast, and it can all the way you could go until you meet your friends for dinner that night after work. So social engagement is included in one's activity of daily living or meaningful activities.

Speaker 2: 2:42

So it is, you know, our job as occupational therapists to really take a look at how somebody uses their time, what is important, what is prioritized in their life, what are those activities that are very important to them, to their family? Also, their roles, you know, we take a look at are they moms, are they dads, are they students, are they athletes? So we take a look at all those activities and assess how they are functioning in each one of those activities. So when you're thinking about eating disorders, you can imagine that all of those activities are impacted. So, you know, as occupational therapists, it's our job to analyze those activities, assess how someone's functioning and really getting to know that individual in order to be able to develop goals and the proper interventions for them.

Speaker 2: 3:48

So, you know, as occupational therapists, we're talking about eating disorders, but we are found in so many different settings schools, you know, to work on handwriting. We are found in the NICUs taking care of preemie babies and, you know, helping parents learn how to do tube feedings. We are found in hospitals and you know, we may be on a, you know, a knee replacement unit where we are helping somebody with those activities of daily living and relearning how to bathe again with this injury. So, again, it really all comes back to having somebody be as independent as they can, while taking consideration, you know, their injury or their disorder. So that is really, it's really difficult. I feel like to explain what occupational therapy is and what we do, because I always say we do it all, we do it all, but you explained it beautifully.

Speaker 1: 4:58

actually, it made so much sense to me when you talked about how do we make use of our time in terms of our daily activities, and I think we don't really think about that consciously and with intention. I walk, I sit, I talk, I'm, you know, talking to you right now. It's not a lot of, it is not intentional, it's very kind of habitual right.

Speaker 2: 5:29

It is. It is, you're exactly right. And it's not until somebody experiences a disruption, you know, whether it's in their eating or they may have some stroke and they have to learn how to dress again. You mean we, how often do we just get up? We grab, you know. We grab, you know, a shirt out of the closet, we put it on our bodies. And when somebody can't do that anymore, it is our jobs as occupational therapists to analyze that activity of getting up, reaching in a closet and putting a shirt on and trying to figure out where that person is falling short of being able to do that skill. So you're right, I mean we, oh, my goodness, on a daily basis we just do things and you know, I always say our brains to fall back to habit all the time. And there are habits. We don't think about it and it's not until there's a disruption in that we realize the skills that are needed to actually function Right.

Speaker 1: 6:40

Right, and that's where you come in as an occupational therapist and with sort of that training and intervention to almost rethink and relearn how to exist almost with intention now that I have to kind of get my shirt out of the closet and how do I put it on with certain injuries and with eating disorders really how to really relearn, to work with my body.

Speaker 2: 7:17

Yes, and you know we're talking. You know we've talked about like a disruption in one's function or disruption in one's eating when it comes to an eating disorder. But I often, you know, occupational therapy also addresses when the person never was able to develop that skill to begin with. So it may not be a disruption at all in you know eating, but more of I never learned the skill to begin with. So there's, you know, actually learning. It's not relearning, it's actually learning the skill that you know developmentally I wasn't able to learn. So that's a big part of it as well.

Speaker 2: 8:01

Is, you know, when we do talk about ARFID? When we do talk about ARFID, you know these, the children and the teens, never, you know, their sensory system from birth maybe was not fully developed or organized, so they never knew the skill to begin with. So you have to take a developmental approach and you have to know developmentally how typical development is and then you have to meet that you know patient where they're at, and then almost have to teach them a skill that usually comes natural, you know. So yeah, so that's a point too of you know occupational therapy. We do teach somebody how to relearn a skill, but then we also teach people how to get the skill that they weren't, you know, born with, or they just never acquired.

Speaker 1: 8:53

Yeah. So could we talk a little bit about ARFID, especially because that's also something that I haven't kind of thought about, learned about, know about almost, because when we think of kids who are picky eaters quote unquote the general understanding is, well, they're picky eaters because they don't like certain foods. And now we have ARFID, we have eating disorders, and now we are sort of in the middle of this spectrum where, as parents, we are not sure what's going on. And I would assume, like with ARFID, like that you would know at a much younger age that there are some sort of things that the child is not able to perform. But could you speak to that a little bit about the spectrum, sure?

Speaker 2: 9:47

Absolutely so, ARFID. I mean, that is, it's like my passion, it's my baby.

Speaker 1: 9:53

It's what I specialize in.

Speaker 2: 9:55

I always say it's a perfect marriage for somebody who has, you know, experienced, such as I do, working in with general eating disorders for the last 16 years. And you know, then ARFID comes on the scene and all of a sudden it's like wow, it's very sensory heavy, oral motor heavy, and as an occupational therapist we are trained in sensory work and oral motor work. So, first of all, ARFID stands for avoidant, restrictive food intake disorder. It's a very long name, so we call it ARFID for sure, which sounds funny. But just talking about the history of ARFID, even though it's new to the eating disorder world, it isn't new to my profession. So ARFID has different subtypes. One of the subtypes of ARFID is sensory food avoidance. So, as an OT, we've been treating, you know, children with sensory dysfunction for the last 30 years, I'd say, which includes the inability to eat certain foods. So you know, we have been treating ARFID. We have just called it different, so it was in the DSM-4 or something different Now in the DSM-5, now it is called ARFID.

Speaker 2: 11:16

However, we are very familiar with ARFID. So what ends up happening is, you know, as an OT, we assess patients with, you know that, come in with ARFID and we determine what subtype of ARFID they have and, like I said, the majority will have the sensory-based food avoidance subtype. So that's where we take a sensory approach to treatment and to the interventions that we use. And you know, with that as well there could be oral motor issues involved. I would say about 50% of my cases will have an oral motor component to it, when chewing and swallowing is not normal or ideal. So it's, you know. That's why it's very important to make sure that patients with ARFID are going to an occupational therapist to have that assessment done, Because again, it's really that's kind of our realm is the oral motor work and the sensory work. If that is not being assessed and treated by somebody who specializes in it, then you know we run into the risk of the child having really only getting maybe half the treatment that they need.

Speaker 1: 12:31

And so how is sort of the interventions with ARFID connected with eating disorders?

Speaker 2: 12:39

Yeah, so another. You know, in my experience I've realized that, you know, at a treatment facility a residential treatment facility that I currently work at, I would say about 85% of our patients carry an anorexia diagnosis along with an ARFID diagnosis. So that you have to be able to have it, you have to know anorexia and you have to know how to treat ARFID as well, because a lot of times they conflict with each other, they're at war with each other. You know, for example, one of you know like our patients with sensory sensory subtype of ARFID sent texture wise, enjoy carbohydrates. They enjoy, enjoy starches, snack foods, dessert foods, when in turn, somebody with anorexia may struggle with allowing themselves to have those foods. So if you struggle with both, you are pretty much at war with, you know, both of them trying to satisfy both and they're very opposite. So in turn, what ends up happening is, you know, I often hear patients say well then, I don't know what to eat, so I'm not going to eat at all, I am not going to put the effort into this. This is too complex, too confusing, too anxiety provoking.

Speaker 2: 14:07

So what's a little bit different is I treat with a, you know, a sensory approach, but then also through exposure therapy. So when you're treating ARFID, if it is a sensory subtype, what's really important is repetition. You need to repeat exposures over and over again, just like we talked about in the beginning of our podcast. We talked about how our brains to fall back to habit and those habitual behaviors we have. So we want to try to have the new behaviors learned through the ARFID interventions become habits.

Speaker 2: 14:46

So we need repetition and we do exposure therapy, you know, and treating general eating disorders such as, you know, the traditional ones of anorexia and bulimia and binge eating disorder. You know I do treat through exposure therapy as well, but what's different is that the intention and the focus and what the goal is during that exposure. So you have to be very, very clear of what your goal is. Are we treating the ARFID with, you know, making sure that we're trying to build emotional tolerance and sensory tolerance together by trying this specific food, or are we treating more of the restrictive anorexia traits and symptoms by doing an exposure but making it clear that we are really targeting the emotional piece of it and those thoughts that keep somebody stuck in their restrictive behaviors?

Speaker 1: 15:46

Wow, that's so much there. Right and what is staggering to me is that you mentioned 80% of the patients at the center are both right, and so I'm wondering if there is a correlation between sort of those sensory issues which I'm assuming have been there since childhood, even birth, and eating disorder.

Speaker 2: 16:25

Yes, yes, we, you know. And with ARFID I must say that you know, research is very new to ARFID and there's not much out. I mean, we're going on about 10 years since when it's been really put into the new diagnostic manual. So research is starting to come out which is great and promising.

Speaker 2: 16:48

But in my experience yes, there I do see a connection between somebody who has sensory issues from birth, who really are viewing food as scary and anxiety provoking because of sensory, you know, issues.

Speaker 2: 17:07

But then it can certainly develop over time into a more restrictive issue where possibly body image is playing a role or fear of weight gain. But again, it's this idea that food, there's these unpleasant consequences to eating food. So it's really important to make sure you're going to a clinician who can really weed all of that out, because you have, because again you're going back to, you have to be really clear on what you are addressing and what the goal of your exposure therapy session is, because it can get very confusing, not only to you but, of course, to the person you're treating. So it's really the assessment piece is so key because you have to ask those questions and really probe to be able to weed out what's the root of all this. Why is food being looked at as a negative thing, you know, a negative issue? Is it because of a traditional eating disorder reason of you know, oh, I don't want to gain weight, my body image issues, or is it a sensory issue from birth, or both?

Speaker 1: 18:24

Yeah, it sort of makes me think about allergies food allergies, right, I mean, because when, when a child is allergic to, you know, eggs and or nuts, there's so much of that anxiety around what, if I smell it, eat it, and what would happen, and then sort of struggling in that space of completely avoiding and it again is a spectrum, right, Like I feel like that anxiety to avoid those things just sort of pops up and it almost seems like I'm going to take a step back every time there is that peace, right, and I'm going to avoid that.

Speaker 2: 19:13

Yeah, that's, you know what. That's one of the subtypes actually of our fit. We consider that a medical subtype which includes GI distress. You know somebody, say, with Crohn's disease, grew up with Crohn's disease and they've learned that food really hurts, can really hurt, you know, physically hurt, and then there's a lot of anxiety that comes with that and then allergies falls under that category as well of you know, I grew up with a nut allergy and you know, now I, you know something that even looks like a nut it's not a nut but it looks like a nut or the same color of a nut causes me anxiety. Or I can't go down the peanut butter aisle at all in the grocery store, even though I need to pick up jelly that's in that aisle. But you know, I've learned that it is very harmful and therefore I have a lot of anxiety around it and therefore now it, you know, impacts my functioning of me trying to go shopping in the grocery store. So yes, it comes with a lot of anxiety and it's kind of.

Speaker 2: 20:28

You know, our fit is kind of this misfit diagnosis where there's a lot of factors for somebody to avoid food, there's a lot of factors that play into it and it falls under this ARFIT umbrella. So you know the GI distress, the allergies, sensory, you know. And then there's the fear of choking. Swallowing, gagging is another subtype of ARFIT, so that's considered our fear based subtype. So again, I mean imagine if you were really scared of swallowing something or food and choking. And you know eating is very fearful, yeah.

Speaker 1: 21:07

Yeah, and I mean that definitely contributes to sort of avoidant, restrictive behaviors. I'm wondering, like in traditional eating disorders, what are your thoughts around the psychosocial emotional connections? Right, and I do understand sort of the sensory piece from ARFIT. But if you could address that connection for traditional eating disorders and we can definitely kind of circle back to ARFIT as well.

Speaker 2: 21:42

Yeah, I mean treating. You know I, we're at the facility on that. I've been there 16 years. I've my role has changed over time. You know, as occupational therapies, like I said, we do it all. You know we really can be put into group therapy and individual therapy and and all of that. But something that always comes up is the psychosocial piece, you know, of eating disorders and you know I really consider like obviously, mental health, the emotional health, social health and spiritual health as well, you know, and really taking all of that in consideration, yeah, yeah, and no one really talks about the spiritual health piece.

Speaker 1: 22:20

So I'm so excited and so glad that you brought that up.

Speaker 2: 22:25

Absolutely. I mean it comes up as again, as occupational therapists, when we're thinking about, you know, how does one function as independently as possible in those meaningful activities, you know, and when I'm used to run groups, all the time I would think of you know we'd run a life skills group and I would. Really you have to consider their psychosocial factors. You know, how is somebody functioning in their spirituality? How is eating disorder conflicting with that, you know, and their values, you know, and also emotional health too. I mean we talk about often building that emotional tolerance. It's kind of like these coping skills that this traditional coping skill groups are not as popular anymore because we are really learning that we need to build emotional tolerance. We need to build a tolerance to the emotion and not so much use distractions and avoid in strategies to push away the emotion, but actually welcome it. So you know all of that needs to be considered.

Speaker 2: 23:31

You know, going back to just traditional occupational therapy, when you're considering the person as a whole, the psychosocial piece oh my gosh is one of the biggest pieces to consider. How is someone, you know, focused functioning in their social environment too? And when I used to run groups, I would always, you know, I do a activity where the patient would need to write a list of what their priorities are, so their life activities, and put them in order from most important down to least, and then in recovery, what do they think their priorities should be? How do they think they should be ranked from most important to least important? And I will say that the one that is impacted the most and from being in your eating disorder and being in recovery is the social piece of it. So leisure activities, hobbies, interests, all of that if the eating disorder always falls to the bottom of the list is affected the most. And then when I asked you know them, where that should fall in recovery, it's always towards the top.

Speaker 2: 24:52

So you know it just shows how much the psychosocial piece is really affected with an eating disorder and it's you know whether it's anorexia or bulimia or arphid either. You know any of those. It is one area that is always affected and it has to be considered when treating and sometimes it's forgotten at times, especially like the spirituality piece. Sometimes that is forgotten when somebody is, you know, in treatment or you're coming up with some interventions for them. So it has to be, it has to be talked about, you know needs to be addressed. You know whether somebody considers themselves a spiritual person or not, but that has to be explored.

Speaker 1: 25:36

Yeah. So in terms of teens, right like I, feel like at that developmental stage they are not thinking about their spiritual beliefs, they are not thinking about even their emotional right, like reactions or the way they feel. They're really primarily focused on their physical. How am I going to be, you know, desirable in my pack?

Speaker 2: 26:05

Yes.

Speaker 1: 26:08

And I'm wondering when they come to you within that eating disorder struggle, how do you approach their needs from an occupational therapist approach?

Speaker 2: 26:25

When it comes to spirituality, I mean emotional, spiritual.

Speaker 1: 26:29

I mean we can tap into each one if it's okay with you, but yeah.

Speaker 2: 26:34

Yeah, you know, especially our teens. So, you know, my practice focus is I take four years old and up. So you know it's important though, even at a young age, to be make sure that you're talking to the parents about spirituality. How do they view spirituality, you know, how do they talk to their children about that. How do they view emotions, their own emotions, how do they speak to their children about emotions? You know that's important, even, you know, with the younger kids. But teens, you know it's still important to, if the parents are involved, to be able to speak to the parents. You know, ask the parents those questions as well.

Speaker 2: 27:13

But you're right, the teens, you know, when they're struggling, they've really learned that emotions are unpleasant and emotions are not needed, and I don't want to feel anything. So you know, having this conversation can be difficult for them about their emotional needs because they feel like sometimes they don't need the emotions because either they feel them too much or they don't feel them and they feel really numb. So bringing that into the equation can be difficult, but it's much needed. You know, if the idea whether you know you're treating traditional eating disorders or ARFID, the idea is to get them as independent as possible. That includes them being able to tolerate the anxiety that comes with doing exposure work and treatment, or comes with learning to tolerate emotions. When they're at a birthday party or they're out with their friends and something unexpected happens, how are they tolerating their emotions in that moment and what emotions are coming up? Can you even identify the emotions that are coming up for you in those moments, those unexpected times?

Speaker 2: 28:29

So I approach it as you know, talking about what they're experiencing in the moment as we're doing the exposure. You know, not only, again, are we building a like sensory tolerance if we're treating somebody who has sensory struggles, but also how does it make you feel to be doing this? Because this is the unknown. Exposure work is all about the unknown. So we don't know how we're going to react to it, we don't know how we're gonna respond and we don't know how we're gonna feel about it.

Speaker 2: 28:59

So, making sure that you're addressing the emotional piece of the exposure work along with you know the sensory piece too, or you know fear-based subtype of ARFID, we are really targeting the emotions there. And that is really difficult for them to do because if they're avoiding food for such a long time because they don't wanna feel that discomfort. I'm asking them to do the opposite, which is to experience the food, not to avoid the food, and to talk about the emotional piece that's coming up while they're doing it. Two things that they have not done in a long time, but it is much, I mean, it is much needed. Avoiding emotions obviously just reinforces that they can't do something, that they can't handle something. So it's very difficult to move through to progress through therapy and exposure therapy if you're constantly avoiding you know your emotions and just reinforcing that you can't do something over and over again.

Speaker 1: 30:05

So that is hard work that is so anxiety-provoking.

Speaker 2: 30:12

It is hard work, but you know the way. My approach to treatment you know whether I'm working at my practice, whether I'm working at the center is easing patients into the work and meeting them where they are at. You cannot go in of having this. You know the same plan for every patient, you see. You know you have to be able to meet them where they are emotionally, spiritually, skill-wise, where are they at, and then build from there. So I really take a graded approach to it, where you know we create hierarchies, we start with the easier to stress foods and we move up to the harder foods while we're building the emotional tolerance and the sensory tolerance along the way and also, more importantly, really being able to build their confidence along the way. So that's what's really important about making sure you're meeting somebody where they're at and taking baby steps to their treatment, because you don't want to overshoot, you don't want to overwhelm them because again it just reinforces that they can't do something Right right, oh, wow, yeah, yeah, absolutely.

Speaker 1: 31:27

So in order to kind of take those people and take those baby steps, there's a lot of work that goes into building their self-confidence, the way they see themselves almost in a different light and like in terms of anxiety, during that time, as you're even with baby steps, it's nerve-wracking to kind of put that one step in front of the other. So what are some of the things that you talk to teens about in terms of handling their anxieties at that point?

Speaker 2: 32:08

Yeah. So it's so important is making sure that you're connecting with them during that assessment period, making sure you're building that trust with them, because we're asking them to do really difficult things, so they have to feel like they can trust you and they're in a safe place to do it. I use humor a lot. I use humor. I do. I always tell them I go into it, you know, during a console. I go into it and I say this is going to be hard but I will make it fun along the way. We have to make it fun and I tell the young kids, I tell my teens, I tell my adults, like the rule is, you have to have fun while you're here, so that you know, takes that anxiety, you know some of that anxiety away. Also, I tell them I do not have expectations, I don't put expectations on us at all. We are just going with the process and we're just going to see what happens. So really taking that expectations and the pressure off of them and doing it in a fun way, I'm telling you has been the key I've been treating like this forever and it works and making sure that the environment again is real fun. And you know I and it's important on the assessment to find out what interests they have. What hobbies do they have? Do they have pets, you know? Do they need to bring in their favorite stuffed animal, you know, to session with us? So you know. Do they need a fidget to be able to get through it? So you know, I allow all of that, especially in the beginning.

Speaker 2: 33:56

I really do because I, you know, in order for them to build tolerance, social or emotional tolerance and sensory tolerance, the food has to go in their mouth. So I joke with them, I don't care if you have to stand on your head in the corner to get the food in your mouth, we're going to do that. If I have to sing a song to you horribly, sing a song to get you to, you know, put it in your mouth so I shut up. Then that's what we're doing, you know. So really having them connect and trust you and feeling really safe really helps with that anxiety. So you know, I think it's very it's different for them if they walked into a very sterile setting and it was just the therapist in them and they sat down and they got to work without much conversation or playfulness, and said you know, here are the goals.

Speaker 2: 34:53

I want to eat five foods by the end of the week. I mean that feels very forced. I would just be focusing on okay, I need to meet my goal and not really focusing on the process and not being mindful along the way. That would be difficult for me. So you know again, just making sure that you're connecting and building that trust and making it fun, that will ease that anxiety, that anticipatory distress in the beginning and then over time. It's very interesting because over time they'll be asking to do the harder foods. I won't even have to ask because they've built enough of that emotional tolerance and enough of that trust to trust the process and to trust you.

Speaker 1: 35:39

I truly love the expectation piece and, of course, like the mindfulness and things like that, and I think humour is such an important piece to therapy. As therapists, you know, sometimes I feel like I take myself too seriously. Especially at the beginning of my career I was like no, I have to be this therapist, I have to make sure you know things actually work. I'm going to put in so much effort and, you know, expecting a little bit from the client to put in the effort which they do, it's just it's not the way I think they should write, and so it's. It's so important to lay off our expectations and take the burden off of them and focus on the process.

Speaker 2: 36:29

And the process. That's so important because, you know, as a clinician, I did the same thing starting off my career I'd focus on those goals. I'd focus on am I getting them to meet these goals? You know, and you're forgetting about the whole process and that is like the meat of it all. That is, the important parts of it is the process and learning to like shift. You know, during the process, if something's not working, you know being able to adapt in that moment. So it's like if we put these expectations on us as clinicians to meet that end goal, and you know how can we expect them, you know, to focus on the process. When we're not focusing on the process, you know. So a lot of modeling is really important too.

Speaker 2: 37:16

While doing this work, you know, and and I think, kind of letting our hair down a little bit while we're treating and letting them know that we are humans, you know I I will eat food with the patient.

Speaker 2: 37:30

So I always have a rule if I'm making you eat this and trying it, I need to eat and try it, and there are some foods that you know I'm uncomfortable eating, maybe sensory wise, but I think it is so important and so helpful for for you to be able to model eating, something that you are uncomfortable with, and being able to talk about that with the patient. You know, wow, I'm feeling really anxious right now. I never had this before, and you'll see how quickly tables will turn and then they start talking you through it and which is so important, because then they're reinforcing what you've been trying to tell them all along. It is okay, you will get through it. It's okay to be scared. You know the emotions are. You know it's important to notice those emotions and let them take the full course without pushing them away. So it's, you know. You have to have fun with them as well, and it really does ease that anxiety in the beginning for them.

Speaker 1: 38:33

So true, so true. And I'm also thinking about sort of expectations when it comes to parents, right, because they bring in their teen to the facility or to you, and a lot of times parents go through anxiety and shame and stigma, and a lot of times it's about them and their parenting, and so it's. There's a lot of struggle and I think with eating disorders in in general, whether it's our food or our traditional eating disorders, there is so much guilt associated with did I do something as a parent that messed it up for my child? And so when that sort of plays a big role, how do you sort of talk to the teen and how do you approach the parents?

Speaker 2: 39:35

Oh my gosh, that's an important question and it's complex, yeah, but yeah. So my approach is I encourage parents to be part of this, this process I do. I mean, when I'm at my practice, it doesn't matter if the child is young, teens, adults. I welcome whoever their support system is. I welcome them into the practice, into our session, as long as the the teen feels comfortable or feels that it's the right time to do it.

Speaker 1: 40:12

I love that, yep.

Speaker 2: 40:14

Yes. So I always ask permission from even the child. I will ask permission. Is it okay for mom or dad or grandma to to come with us to be in here, or would you like grandma or you know a mom or dad to wait outside for half of our session and then you just you tell me when you want them to come in? So you know, I want them to feel like they have control over it, because if you think about RFID, I mean other eating disorders as well.

Speaker 2: 40:44

But think of the struggle that these families have probably gone through since childhood or since toddler years of you know, those meal times and trying to get their child to eat because they're so concerned that they're not eating. And all of you know the the strategies they probably used to get them to eat. You know, such as hey, you know, here's a reward system, you eat this, then you get your tablet. For you know tonight, or you know so, it has been very hard on both the child, the teen and the parents this whole process so far. So you know I approach it with kid gloves. Of course you never want to blame parents. You know it's it's not their fault that their child was born with maybe their sensory system not perfectly aligned and most of the time they listen to the pediatrician and they, you know, and sometimes the pediatricians I've noticed have taken somewhat of an old school approach of you know, when a child's hungry enough, they'll eat, which is completely incorrect, not helpful and incorrect. So they've tried their best. You see them really exhausted when they come here, really relieved that somebody is listening to them and validating that. Hey, there is a issue. This is not a parenting issue. You didn't do anything wrong. You know, maybe the approaches, you know we're going to change up your approaches to it and that's my job to help find the better approaches, of course. But you know I tell them right off the bat it is not your fault. You've done the best you can. You've probably listened to other, you know, practitioners or clinicians. Maybe things worked, maybe they didn't work, but you're in the right place and we're going to figure it out together. You know this is you're not by, you're not alone anymore. You know you have somebody on your team now that can guide you and to help you support your child.

Speaker 2: 42:53

So, like I said, I really encourage them to be in session because I also am trying to model for them as well of the do's and don'ts. How do I approach asking the team to eat something, how do I react when the team is not ready to try that food? You know how do I handle that. You know being having the team, you know be able to say what's helpful, what isn't helpful, that I'm doing with them, or what's helpful or not helpful that their, their parent, you know was doing or not doing. So most parents that I will tell you it is very rare for a parent not to join our session. They want to learn, they want the guidance. So you know I've just found over time that parents feel very relieved once they had their child at, in the right treatment, in the right place and with the right therapist, very in there, so eager to, you know, to change their, their strategies up and, you know, and being able to talk to the parents about their emotional experience with this as well.

Speaker 2: 44:07

So I also do a really fun session with parents, once the the team tells me that we can do it and we're ready for it, where I bring the family members into the practice and I blindfold them and I have the teen.

Speaker 2: 44:26

They will present them with food and then they will ask them to try it, and what that does is it gives the caretakers parents, family somewhat of the experience of what the teen goes through when I'm asking them to try new foods. And then it's interesting of you know asking them how did you tolerate your emotions while doing this? What was it like for you, what was your emotional experience? And I'm telling you that is so beneficial to do that session with them because you know they get very emotional. They get very emotional because they say, oh my gosh, for the first time I'm experiencing what my child or my team has been experiencing their whole life with this trying new foods. This was one or two foods that was really hard for me. I can imagine all the years you know I've been asking my child to eat these new foods and what that experience has been like for them. So you know, but making sure that you have the family involved it is so key to have the family involved in this work.

Speaker 1: 45:37

Yeah, I mean that sounds amazing to actually experience something and be empathetic, you know, towards our teens, our children, and understanding where they are coming from, because it's really hard at times as parents to sort of figure out, especially around food, and I feel like a lot of it also comes from our cultural backgrounds right.

Speaker 1: 46:04

Like growing up in India, I mean, if we didn't eat certain foods, it's like really, whatever is on the plate, you have to finish it. There is, there are no options and this is the food you get. And so if we said, oh, I don't like certain foods, it was like sorry that you don't like it.

Speaker 2: 46:24

You have to and you know you're you're saying, yeah, we're talking about growing up in India, but I, you know, I experienced that with most of the parents here and a lot of times it's the dads that have that idea of, hey, like I'm giving you this, either you eat it or you don't eat it, but like we're not making separate foods, this is what it is.

Speaker 2: 46:47

So it you know I have to do some of this psycho education with them on what our food is and that this is actually diagnosis. This isn't so much a behavioral problem, you know, of I'm just digging my feet in and saying I'm not eating this, you know. No, you know this is actually an issue, a sensory issue. So you know that can be pretty difficult, I'll say, for the parents to hear, because then that guilt comes into play, some shame comes into play, but again, reminding them, you know this, you didn't know what this was. You know the intentions are always good. You know you're trying to get your child to eat. That is your job as a parent to do that, but it is, you know, it is really important to make sure that you are listening to the parents experience and their emotional experience and being able to, you know, emotionally coach them through through this journey as well.

Speaker 1: 47:45

I'm also thinking, as you know, as parents, and especially when we throw in culture, sort of the value system that comes with it, right, and we bring that to food and we bring that to our children. And part of it is also that teenagers are rebellious and they they, there are sort of which is great, they have, they should be as they're growing up, but as parents, we see that more as challenging us. And then when we put in foods, it's almost like a struggle, a power struggle, and when we think of sort of traditional eating disorders and when teens are sort of resisting certain foods, restricting certain foods or binging on certain foods, and even and I'm thinking culturally, not just in terms of race or ethnicity, but also sort of the diet culture that we are in or even thinking about I'm going to go plant based or I'm going to do keto as parents, because we are thinking about health, right, sure.

Speaker 2: 48:56

Or I'm going to go vegan and yes, right.

Speaker 1: 49:00

How do you I mean in your practice have you seen that struggle and then it when it comes to traditional eating disorders like how? How do you process that?

Speaker 2: 49:15

Yeah, so, but you know my approach. I kind of say to the parents and I say to the patient I'm going to be the food police here. I'm going to take that off of you guys Right now. Your job is to support the work that me and the teen are doing together. So I, and then they're like, oh gosh, this is great, I don't have to be the food police, jacqueline's going to be the food police now. Yeah, okay, I'm here just to support in their job.

Speaker 2: 49:41

I always give my patients homework to make sure that the exposures are being done outside of this office, because they get so comfortable and safe, they feel so safe here to do the exposure work here. And then they they have a hard time transferring it to home and I'm like, no, no, no, like you know, we need to do things at home as well Exposures. So I say to the parents you're off, I'm taking it, or being the food police. You know you're going to see how I approach these issues, what my philosophy is on diet culture, what my philosophy is on health versus unhealthy and labeling foods. You're going to see my approach and my philosophy and I really would like for you to to adopt it right now. So it does take a lot of discussions with the parents about what their philosophy is on health. How do they label food as healthy and unhealthy? At home Do they use the terms junk food, which makes my skin crawl makes my skin crawl.

Speaker 2: 50:51

You know, but it takes all. I mean it's not and I always say this is a family illness. This isn't a one, this isn't a teen illness, this isn't my child's illness. This is a family illness. So it takes a family to help the person recover. So they need to be educated on the unhealthiness of our culture at times, of this diet culture and these fad diets and you know, sometimes parents come in on these diets. Well, I follow keto, so I cook keto for my family. Okay, well, this is not going to be helpful right now because we are trying to add variety into somebody, your teen's life, not take away. So the more restrictions you have on your eating, the harder it's going to be to add variety to your life. So if the goal is to add variety and well balanced, a well balanced meal plan, yeah, then that includes the junk food, that includes the unhealthy food and really being able to educate them on why our body needs the junk food. You know why our body needs fats and carbohydrates. So you know again, going in with kid gloves, you know, being empathetic, being gentle, but being able to have these discussions with the parents that you know we are going to take labels off of food during this process, because this is not going to help the goals to add, not take away. So it's really important to ask them again what the what are their, what's their nutrition philosophy? You know, in their home, what do they allow, what do they not allow, how do they talk about food? So, making sure that you are addressing all of that in the very beginning. You really need to set that tone in the beginning and you'll see and I am so.

Speaker 2: 52:52

I always say I have the best parents at this practice. I just am so lucky to work with the best parents out there and they really, they really want to change their mindset to. So at first they're a little shocked by it and like, wait a minute, this feels sounds very different. You know, if they know that it's going to help their child, they kind of forces them to. Then to look at how they're eating.

Speaker 2: 53:17

Do they have a well balanced meal plan? Are they including those, you know, forbidden foods, are they not? And you know. So it is again like a family discussion, because the way that I look at food and the way I treat needs to be reinforced at home as well as the best they can, because, again, that homework is really important, so I need the parents to support them doing their homework. And you know and I'm always open for questions and ideas from the parents and I love getting emails like hey, I was thinking about this, can we try this or can we talk about this next week? This has come up a couple times since the last session. So making sure that they're all the families included.

Speaker 1: 54:06

I love that and the fact that you help parents take that burden off. You know, as a parent it's already like stressful bringing in your own anxieties around what's happening with your teenager. So to have that almost like that relief from not stressing out so much about what they are eating, how they are eating, why they are not eating or why they are eating too much, is really helpful. I know I've taken more time than I had asked for. That is okay. This has been such a wonderful conversation and I truly feel like I can talk to you for another hour.

Speaker 2: 54:54

Oh, my goodness.

Speaker 1: 54:54

You have so much wisdom and experience in this field. I hope you come back and we can talk more.

Speaker 2: 55:03

Oh, I would love to. I'd love to, I would love to come back. This was a lot of fun and parents really need this information because it's not that accessible. You can Google as told for hours and hours and hours, but there's not enough information out there. So I mean, you're doing a wonderful job and I appreciate you putting this out and to help parents and help teens and, you know, obviously help the field too.

Speaker 1: 55:33

Thank you so much. Thank you, and I will talk more.

Speaker 2: 55:38

Absolutely.

Speaker 1: 55:40

I truly hope that you enjoyed this conversation. My goal is to provide you with in-depth discussion on topics that concern us as parents of teenagers and young adults, and provide you with resources to get started. Have a beautiful week ahead. I would love to hear from you on our Instagram page for parents of teens underscore podcast. See you back here soon.