Eating Disorders Across the Spectrum: Recognition, Assessment, and Evidence-Based Care with Erin Alfree Williams - Part 2

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Transcript

Speaker 1 0:27

Hello and welcome to Mind and Medicine, a Sentara podcast. I'm Tommy Bateman, your host, and today we will be meeting with Erin Alfree Williams to talk about eating disorders, a very complex topic. But before we begin, some important CME announcements. This episode is accredited for AMA PRA Category 1 credits. For full accreditation, designation, and disclosure information, please refer to the show notes and now the show. Alright, welcome back, Erin. Um, and so last time uh we were talking about the uh kind of an overview of eating disorders, what they are, kind of what's behind them, uh prognosis. We went over it all, and I encourage everybody to listen to part one. Uh but now we're gonna talk about treatment. Okay, we have we have a good idea of what we're we're dealing with. Uh somebody walks into a clinic and uh through assessment, you're you're you're a smelling eating disorder. So where do you go from there?

Speaker 0:59

Yes, yeah. So I think when we start thinking about you know the approach to treatment, that screening process is so important because it's it it really gives us a window and an understanding of where the struggle is for somebody, maybe some of the other factors or circumstances that could be influencing it. And I think one of the main things to get out of the assessment is not only so much what causes an eating disorder, but sort of what are what are the things that are helping to maintain sort of repeated patterns and behaviors for someone? Your standard approach to any type of screening is going to be asking about their eating habits. How many times are you eating today? What type of eater are you? You know, are you do you graze throughout the day? Um, you know, when you skip meals or skip eating, you know, how do you feel about that? So a lot of the a lot of the screening questions typically are about sort of the the behaviors and and you know what someone's routine looks like and and what they're doing throughout the days between eating and exercising, but then also how do they feel about it? You know, do you feel very distressed after you eat something that you didn't think you're gonna eat a whole lot of? Um, do you feel really worried or anxious if you miss a day of exercising? And a lot of times that can give you some indication of you know where where is where does this exist on the continuum for someone? Um, I think, like I'd said in the the previous podcast is also talking about like how much mind space is this taking up? How often do you think about your body, what you look like, how you feel in your clothes, are you comfortable? Are you anxious or concerned about what other people are thinking of you or how they're perceiving you? And then trying to get a sense of how of all of these experiences really inform someone's decision on how they're eating, how they're taking care of themselves, um, and how they're taking care of their body.

Speaker 1 3:11

I'm having trouble where to take this conversation because as you said, it's a contendulum. So let's start with let's start with severe, right? I think it's rarer, I'm assuming it's rarer than the the um than less severe, um, because it generally is, uh, with other things. So we start we have a severe candidate. You're you're an outpatient clinician or a doctor, uh, you're the PCP and you have a severe candidate come in. Um what where do you go from there? Uh where do you refer to? What uh what's what's the appropriate course of treatment for this individual?

Speaker 3:49

Great question. Typically in the setting of primary care or even an emergency room or some sort of medical setting. Sometimes there's sort of a natural window of opportunity to engage in someone's conversation about this because you have the health parameters to look at, you know, weight, body mass index, lab work. You know, those are sort of the three major, major things that you're gonna explore and that are gonna be immediate feedback to see where someone is, you know, um based on someone's height and and weight, you know, does that look like it it makes sense, you know, in terms of their body mass index? Labs are going to be a big indicator, although uh an odd phenomenon with eating disorder is that you could have someone that is regularly engaging in symptoms and their labs be totally normal. I've seen that happen. Um, so that's where I think the thorough assessment really becomes paramount because you can't just rely on one single test or scan or lab value to really show that there's an eating disorder. It's usually going to be a number of things that kind of paint a picture of it. Then when we start thinking about, okay, we we've identified that there's something going on, what's next? Really, I kind of similar to you. I start at the top and and work my way down. You know, are we at a point where somebody is very medically compromised that they have to be on an inpatient level? And usually that's going to be because of lab values or are really off. Um, there's maybe a cardiac concern, you know, happening here, um, maybe a uh nutritional deficit, you know, something that's going to be affecting someone's GI health that occurs. Um and uh, you know, it is that level of care needed. Um it's interesting. Most people in my experience are very accepting of treatment of, like, oh yeah, there's something medically off. We need we need to pursue something for a higher level of care. It's when you start to really explore, oh, there's something more mental and emotional going on here that we need to disrupt, what led someone to this point that they needed inpatient care, that it can become more difficult because there's can be a lot of resistance to pursuing some something such as a residential program or a partial hospital program.

Speaker 1 6:26

The way you're talking about it, I'm wondering, are you saying that for the for the highest need, do they have to go to medical inpatient first, get medically cleared before they can enter eating disorder treatment, or can it be concurrent?

Speaker 6:38

It depends. It really depends on the medical profile, I think. Um it requires it depends on if something needs to be medically stabilized. Because again, somebody with a a severe eating disorder, there's so many systems within the body that are going to be thrown off, and they're major ones, such as your cardiac health. Um, you know, it it's not uncommon for individuals to um, you know, have an EKG done just to see, you know, how's your heart functioning? Um, and if there has to be immediate intervention, that's gonna require inpatient level care. Um, you know, if they're really nutritionally deprived, it may warrant tube feeding and sort of a monitoring for refeeding syndrome, which you know can really kind of create a whole slew of medical issues. So again, it really depends on how the patient's presenting, how the body's responding to maybe some introductory efforts to treatment. Um it's not always needed that somebody go directly inpatient. They may be able to go to a residential program with some minor, you know, medical clearance and and some tests and values. Um then in terms of excuse me, the facility, the accepting facility or the places that will provide treatment, they will offer those parameters and say, you know, here's what we can handle, here's what we can't have handle, this has to be stabilized first.

Speaker 1 8:07

And and so that and that that was my my concern too is that I I bet this is such a barrier to care that you get somebody medically stable back on their feet again, feeling good, and then they just don't engage in care. I think that's what you were getting to at that point earlier. Was that they're gonna they're they're just fine getting fixed back up, but then once they're medically stable, the the mental health side kind of is not something they're interested in in dealing with.

Speaker 8:35

Yeah, this is where I think that line between medical and mental health really starts to blur because then you really have to begin to assess, you know, does somebody have the capacity to make a decision for what they're doing? You know, it's it's not necessarily a crime, it's not necessarily a um uh uh, you know, you can't you can't force treatment onto somebody if they don't want it and they're of sound mind and body. And that's what's hard, is it? And so it's sometimes having to talk to individuals about your assessment, what you see happening, what your recommendations are, and and kind of know that you're you're likely going to encounter some level of resistance or denial in that.

Speaker 1 9:23

It's so difficult. I I I remember uh in emergency services, I had somebody else assessing for a TDO, you know, as an eating disorder case. And I go, Well, is there a threat of imminent harm? I'm like, no, no, maybe no. Um, are they psychotic? No. Um, do they wish to hurt themselves? No. I'm like, and it was so, so nebulous. It's not as clear, but psychosis and easy, gotcha. You know, suicidal ideation, gotcha. This one that was so hard to, you can't force that treatment. It it and so I see why there's such a cycle of people getting medically well, relapsing, going into treatment, relapsing. Um, it's it's very difficult.

Speaker 10:10

I often tell, I often get a question, you know, in terms of, you know, you are a loved one or you want to talk to someone about their eating disorder or address it, and and what is the best approach? And one of the first things I always tell people is be prepared for it to not just be one conversation. It's rare that you have a one-time approach to someone and say, you know, I'm concerned about your eating, and someone go, Yeah, you're right, let me go seek treatment. It's usual, multiple conversations. It's it's, you know, maybe trying something and and you know, they're not being in agreement or someone being on board with it right away. Um, but it takes some time because again, with an eating disorder become comes a lot of complexity, complexity and a lot of distortion. Um, and and finding ways to engage someone around that, help them get to a point where they can acknowledge this is a problem, um, but then kind of get to that next step, which is accepting, hey, you know, there are services for this and there are ways to get better. But again, it's it's you then start to get folks into a realm where it's going to feel really uncomfortable, even though we know it's change that is good and would lead to better health and and better outcomes in the long run. Change is scary, you know. Um human beings like knowing um what to expect, they like leaning into things that are comfortable, comfortable and tried and true, even when they are not the best or healthiest behaviors. You know, we see a similar thing happen in addictions, um, you know, where it's sort of a go-to coping skill. We we know what to expect, how to expect it, and pulling someone away from that can can take some time.

Speaker 1 12:06

So, okay. So let's say we get over that all. Let's say we got the person medically cleared and stabilized, they actually are contemplative on change to pull in that term, and they go to treatment. And let's say they're severe case or they go to a residential treatment facility. What can they expect there? What type of interventions are going on there?

Speaker 12:27

Yeah. Um at the residential level, and I would even say at like an intensive outpatient level. Um there's a there's a really neat diagram that you can find on almost any eating disorder website. It talks about sort of the multidisciplinary approach and sort of the ideal the ideal uh picture of care is gonna include multiple disciplines, which is gonna be counseling, uh medical primary care, psychiatry, nutritional. Um, it's going to include uh some of the better programs are gonna include family counseling or some sort of support person or someone in their community being drawn into it. Um at the residential level, obviously this is it's your care is 24-7. So your whole day is structured around weight rest weight restoration. It's structured around, you know, sort of multiple counseling sessions throughout the day where you're discussing your relationship with food, you're discussing your fears, you're discussing phobias, um, you know, speaking to the complexity of things. You may be venturing into talking about past trauma experiences, um, you know, abuse being one of the biggest things that can influence how someone feels with their body, um, addictions. Um you're discussing uh meeting with medical providers to talk about medication, but then they're also monitoring your medical health. So, you know, you're routinely getting lab work done, um, scans if necessary, because with eating disorder, it affects so many different realms. You need all those different things to take place in treatment for there really to be a comprehensive recovery approach.

Speaker 1 14:25

So, side note there, you know, as a clinician, I mean, I would like to be able to generalize this and go, you know, say, well, anxiety disorders that usually is dealing with this sort of function, and we can we can treat it this way. You know, there's depression, and you know, it's with this one, it sounds so complex and that yes, it manifested as a disorder, but behind it could be all kinds of different things a delusion, uh a delusionist disorder, uh, anxiety, personality disorder, another an addiction, and they all have different approaches. So what I'm hearing here is it really takes a special clinician to do this type of work.

Speaker 15:06

Yeah, it can. It can. Um, and it's gotta, I think it takes a special clinician, it also you know takes somebody um, you know, yes, with experience, but also with a comfort level and and sort of a um uh a variety in their skill set. Because like you said, you with eating disorder, so many different things could be coming up. But I think being a clinician, you always kind of keeping it sort of in check with hey, there is this other thing happening, which is the eating disorder, and and trying to work with a patient so that you're holding them responsible for addressing the day-to-day stuff in terms of how they're caring for themselves, but then holding space for maybe the things that are unpleasant that you're having to explore. Because again, what we're trying to get at the source of in the counseling side of things, is yes, there may have been causes for the eating disorder, but what maintains it and how do we disrupt that? How do we change that? How do we develop different coping skills? How do we, you know, develop sort of techniques that that help prioritize us and our identity and not the identity of the eating disorder?

Speaker 1 16:23

So, not to jump around a whole lot, but I jump around a whole lot. Let's go back. Okay, we diagnose somebody with an eating disorder right before we do the treatment side, it's actually not as severe as the one we were just talking about. There's no medical complexities here. They just have, I say just have, but they they have a disordered relationship with food. That one of those non-otherwise specified issues that we were talking about earlier. Um, what's the next step for there? You're let's say you're a physician or an intake worker, and and this is what you came in with, uh, it came to the conclusion. Where do we send this person next?

Speaker 16:58

Yeah, great question. Um, again, always start with with uh counseling referral. And again, if it if your area allows and has that option to access somebody that has a specialization in eating disorders or at least experience with it, um there is there is a um a designation for for uh someone that specializes in eating disorder. It's a CES, it's a certified eating disorder specialist. And those are clinicians that you know have put so many hours into working with individuals with eating disorders. Um but again, a referral to any type of counselor that can engage in those conversations with people and kind of do a full assessment to figure out, you know, what is it that's going on? Is this something that you know we can address from a relational side of things? And this is sort of, you know, we can address an eating disorder from that side of, yeah, you know, I had a hard upbringing, I was bullied, I had, you know, a lot of peer pressure, performance pressure. And, you know, if you find a clinician that is willing to address those topic areas, you may kind of naturally get to um some of the things that help maintain or or influence uh disordered eating behavior. So I think a referral to a counselor is always a great start.

Speaker 1 18:20

Um and so, and there's such, you know, you and I both worked in in the field where we have to transition from somebody from one level of care to the next, or you're in the emergency room and you see what you have and you go, all right, now I gotta find care for this person. And that designation you mentioned earlier is rare in the field. Um finding uh finding somebody that specializes in eating disorders and willing to take that on is a very, very difficult thing to do. But uh I'm wondering, is any counselor, you know, any meeting, any good professional counselor or therapy, any therapist all better than none in this case, is uh or do we need to have that special specialist?

Speaker 19:05

Like anything, I think it depends. You know, I think getting to an experienced clinician, somebody that can kind of help people comb through the details and and assess what's really needed in the moment. Um and then if you know that clinician were to decide, like, yep, you know what, I think this is maybe beyond my area of expertise or a scope of care, you know, we are ethically required to to help somebody connect and find another provider that would be a good fit. Um but I recognize that it it can be very difficult. You know, the barriers you people are facing are just geographical location. Like I'm located in the Shenandoah Valley, you know, this we're very blessed with having lots of counselors around here, but um not so much sort of plentiful people with lots of experience in certain specializations. Um, sometimes it requires individuals, they may prefer meeting with a clinician in person, but you know, being flexible to maybe meet with someone virtual, um, because then we're able to access somebody in a different area that has that specialization. Um, and of course, you know, then the other barrier of affordability, you know, do people have the means? Do they have the insurance coverage? Is that clinician a network with them? Um, you know, so so there are so many ours, it can feel like there are a lot of a lot of barriers to accessing that care. And it it does take a little bit of work to kind of filter through and find the right fit.

Speaker 1 20:39

Absolutely. And I we're in the health plan, we have, you know, I've worked for another health plan before. One of the biggest barriers is just access, um, especially for the uh more severe cases. Uh pretty much the the rule of thumb in in Virginia is uh single case agreements to an out of state provider because we don't have enough, hardly any in Virginia, um, which I find amazing. Uh but yeah, we've had to send many, many cases out of state just to get that you know high intensity care that that person obviously needs. Um so yeah, that's it's uh anybody listening and wants to start an eating disorder clinic in Virginia, please do.

Speaker 21:22

It's a topic area in a field that I think is is always going to be in demand and it and it is very specialized. To circle back to something I referenced in the original in the first podcast, though, I think it there's a piece of it that I think is because of the pervasiveness of the topic area. You know, this is this is something, you know, eating and and body image is something that everybody has to be attuned to. Um, it also requires you, as a, you know, from the clinician side of you to really take some time to think about your own relationship with your food, with food. and body and what those you know cultural messages are, what those um you know core statements you have about yourself because that will you know in some way shape or form emanate in your work. Um and and and for I mean for simplicity's sake it's a very vulnerable topic.

Speaker 1 22:20

Um yeah and it makes me so let's encourage some of our therapist friends out there. You know it is it is a difficult thing to do but I often when I was when I was treating um let's for example uh uh a panic disorder I mean I'm working with somebody with a panic disorder I I found working on the secondary disturbance uh which is their anxiety about having a panic attack actually helped alleviate the panic attacks. Yeah. And I'm wondering as you said there's always something and we mentioned it could be a variety of different things behind the eating disorder. But if we address the secondary issue I say secondary um which I feel much more competent to do than the eating disorder itself. You know I feel very if you're coming to me that the person's having some um it's self-esteem issues, oh I got you right I can do that all day. And I can treat that and help and help the person develop skills for their self-esteem issues. Am I helping the eating disorder? Is that something that we can do to help the the broader eating disorder problem.

Speaker 23:36

And I think that's where the multidisciplinary approach can really be helpful you know because it in the counseling realm are you necessarily going to be addressing the eating disorder every session no it may be some of these underlying issues and and for anybody practicing in the field it's going to be one that you know you're gonna have small successes throughout the way this is not someone that you know this is not an individual you're gonna work with and there's going to be an immediate turnaround and and you know progress of like hey I'm much better but something that sort of occurs and you know um modestly or minimally over time. But having that multidisciplinary team you know you know that if you're addressing sort of to go with your example you know the self-esteem side of things then an individual goes and meets with a nutritionist well then they're addressing sort of the the eating the intake the nutritional restoration that that's kind of happening and so in some ways there there are ways to kind of indirectly I think influence the eating disorder by addressing some of these underlying things um I think as clinician though it we are responsible for making sure that we're up to date on you know what what transpires what does an eating disorder look like and if somebody is not doing well at that point then saying okay I think we've gone beyond what we can manage at this level of care and something higher level is needed um and that can always be a hard conversation so yeah with both the severe cases and the moderate and less severe cases we have an individual we got this individual through the continuum of care.

Speaker 1 25:26

Their relationship with food is much better they're eating normally they're healthy um is there ever a time that I guess a primary care physician or anybody treating within this case should not be concerned about relapse um or is this a lifelong monitoring situation?

Speaker 25:49

Yeah great great question in some ways yes it it it is you know because it is and it it really depends on again someone's I think someone's ability to get to a point where they can recognize that like I'm comfortable with myself I'm comfortable with what I'm eating but sort of spending some time in treatment to identify what would be the things that would really pull me back into this you know and so engaging your patient in conversation and having them identify what are their warning signs, what are the triggers what are it's some of that future planning, you know, of kind of saying like hey I am in a good place things are recovered I'm I'm stable but what could potentially be some things that would throw that off you know and and just exercising some awareness around it and maybe even some planning of if this does happen, then I need to do these top three things, you know, whatever that may be so that you prevent sort of a very quick and a very abrupt and a very worrisome relapse process.

Speaker 1 27:03

Not to be too reductionistic but it this sounds so similar to substance use treatment.

Speaker 27:08

Exactly exactly yeah and a lot of times you know this is where I think as a clinician it it's really important to engage the patient in a way that they feel like they are at the center of their treatment you know because as as a clinician I can offer suggestions all day what's going to work for one person may not work for another. So a lot of times I will ask them and say, you know, what do you think are your warning signs? How what would be your threshold of knowing hey I'm dipping back down into an area that's dangerous. And usually if you provide the time and space for a patient to identify that the the more likely they are to kind of follow through with some of that safety plan or that future plan should something happen because it's that self-identified I I've hit a parameter here that I'm not comfortable with and let me do what I need to do to get back on track. I have a magic question for you then you know in our final minutes here if you could tell the audience one or two things that not necessarily a magic bullet here but in the realm of eating disorders what's what's one big thing that you would like the audience that because these are all you know people that engage in treatment are some some way tied to eating um to treating people what would you want them to know about this that would help our members and clients and patients um overall what would I want individuals to know like if they walk if they walk away with anything what would you if they walk away with anything um this may sound a little cliche but I think it you know hold hope that it can get better um I think with eating disorder sometimes it's very quickly to feel like uh this is so complex and there's too much going on here I don't see how I could ever combat this or get to a different place. And I think just leaving people with the message of it's possible it can happen. Having a healthy relationship with food, with your body with whatever occurred in your past is possible and you can get to a place where you feel much more comfortable and and to not lose sight of that.

Speaker 1 29:39

And if and if it does feel like it's a hopeless process please reach out to somebody and have a conversation because because it's not and on that note then uh Aaron thank you so much for joining us today. Any final words besides that beautiful one you just left us?

Speaker 29:56

Oh thank you. Not that I can think of I just I always tell people be kind to yourselves be kind to your body the only one you get um and um it's it's meant to be your mechanism of of working with you through life. And so anything that we can do to help you please reach out.

Speaker 1 30:14

You've been listening to Mind the Medicine U Sentera podcast as a reminder please check the show notes for details on how to claim your continuing education credits as well as any resources mentioned in the episode. That's it for now but keep an eye out for another episode and more evidence based education for healthcare providers on the go. You welcome