Episode Transcript
[00:00:00] Speaker A: Welcome to the Art of the Referral Podcast where we explore the nuances of mental health referrals to better serve our patients and our communities.
I'm your host, Anna O'Brien, a practicing licensed professional counselor and co founder of Be well Private Practice Communities and theravera Care Connection Technologies. I'm passionate about creating a stronger professional community that works together to reduce provider burnout, increase continuity of care, and ultimately improve the lives of people living with mental health challenges. Each week we dive into a different specialty or supportive tool, bringing you expert interviews, practical advice and inspiring stories to help you master the art and ethics of referrals. Join us as we navigate the complexities of patient care, enhance our professional skills and build a more connected health conscious community. Let's get started.
[00:01:03] Speaker B: Welcome to the podcast featuring James Runyon, a highly experienced professional in the field of eating disorder treatment. James brings over 35 years of experience in treating severe mental illnesses, behavioral disorders, addictions and trauma, with 30 years dedicated specifically to eating disorders.
As the Executive Director of Healing at Hidden River, a residential treatment program for teens and young women with eating disorders, James leads with extensive expertise, his impressive career. Hold on a second, let me just start that over again. I just like to punch it out and be good.
Welcome to the podcast episode featuring James Runyon, a highly experienced. One second, James. You know what I don't like is that I'm looking down, so I'm going to put this in my teleprompter. I promise I won't be this perfectionistic as we get going, but I just. I value a strong start.
[00:02:06] Speaker C: Yeah, usually.
[00:02:27] Speaker B: Okay.
Welcome to our podcast featuring James Runyon, a highly experienced professional in the field of eating disorder treatment. James brings over 35 years of experience in treating severe mental illness, behavioral disorders, addictions and trauma, with 30 years dedicated specifically to eating disorders. As the Executive Director for Healing at Hidden River, a residential treatment program for teen girls and young women with eating disorders. James leads with extensive expertise. His impressive career includes roles as a consultant, executive director, chief Operations officer, clinical director and program director in various eating disorder treatment facilities. James credentials are noteworthy, including being both a California Marriage and Family therapist and Arizona licensed professional counselor and an IAEDP certified Eating Disorder Specialist and fellow. His leadership in the field is further highlighted by his past presidency of the International association of Eating Disorder Professionals Board of Directors. With his wealth of knowledge and experience, James is here to share valuable insights into the complexities of eating disorder treatment, referrals and the importance of specialized care. Welcome, James.
[00:03:52] Speaker C: Oh, thanks, Hannah. Thanks for having me on.
[00:03:56] Speaker B: Absolutely I'm so excited to chat with you about this topic. Referrals are something that are so important professionally so that we can stay within our scope and provide the best care possible. And among the different specialties, eating disorders is a very niche referral that, you know, there's a lot that goes into the training, and we often sometimes don't recognize that our patients or clients may be struggling with disordered eating or an eating disorder until we get further into treatment and trust is established. So this podcast is really aimed to support providers and understanding things to look for kind of the what, when, how and why to refer. And James is going to share with us his knowledge around the different areas and just kind of arming us with enough knowledge to support that process. If you do need to assess for referral, and if you do decide to refer, how to go about assuring that the person gets the proper level of treatment.
So exciting to begin this journey with you as we talk about this, and I just wanted to start by asking you, what do you think are some of the most pressing issues that you see relating to eating disorder? Clinical referrals?
[00:05:19] Speaker C: The eating disorders themselves are very difficult. And there's a number of things that a clinician, whether it's a therapist, a dietitian, a doctor must be aware of. And the reality is we're all trained in our discipline, and yet our knowledge of other disciplines based on what a patient's presenting, we must have some recognition of that.
And that's part of our challenges. Our education might be somewhat limited so that we don't know really what to watch for. So to lead out with eating disorders, particularly when somebody presents. The most common issue people might recognize is somebody, if they look at them physically, would be that somebody's underweight.
If some. That's. And that might lead towards anorexia as an example, but that there's a misnomer in there, that a person who struggles with the symptomology of anorexia must be underweight. It's not. Not accurate whatsoever. And that would then begin to create some kind of missed opportunity for a proper diagnosis and a proper referral.
The other eating disorders that might factor into somebody who is struggling with malnutrition, yes, it most commonly could be anorexia. It could be bulimia. And a person who has bulimia can look perfectly normal from the outside, and yet inside, based on their medical condition, they could actually be in a more dire position than somebody who is emaciated.
Then a third area, and I'll go to the Other spectrum of somebody who has binge eating disorder? Well, it might be thought that somebody who has binge eating disorder is significantly of a higher body mass. It's not accurate. You could have somebody of a significant higher body mass that is a binge eater, and yet you could have somebody who is a reasonable body mass, that is a binge eater. And it all depends on what the dynamic is. Now, what I find in working with professionals who are new to the eating disorder realm is that breadth of knowledge covering all the spectrums of potential presentations just isn't there. And we have to educate ourselves in a number of areas to be able to cover that ground.
[00:07:46] Speaker B: Absolutely. And one thing that came up as you were chatting too, I was thinking about orthorexia. You know, we're starting to see a rise of a bit of obsession around healthy eating.
How do you see that kind of showing up within treatment? And is that something that providers should be kind of looking for as well?
[00:08:06] Speaker C: Right. Orthorexia is not an official diagnosis.
It's a term coined to cover the idea of somebody who wants to eat healthy, but has taken it to such an extreme that they literally have begun to reduce their energy intake, which is food, to a point that it doesn't sustain their health. And so when you look at orthorexia, you're really looking at a mindset. But on the spectrum of an eating disorder, you're looking at what is the energy or the food that they're ingesting and is it sufficient to sustain healthy body position, mind function, those type of things. And then from there, where do they fall? Because they could go into the realm of such malnutrition that it would look more like somebody who is emaciated.
Or they could be doing some.
I've worked, I've also done private practice for a number of years and I would have people present that way and they'll talk about their healthy eating pattern. But when you really begin to assess, they also over exercise. And that exercise could be a bench process or a purge process. I'm sorry, a purge process. And so really what you're dealing with is an eating pattern that is insufficient for their condition and their amount of energy that they expend. So in that case, I'd probably put them maybe in the realm of bulimia, or it could be anorexia, purged height. So that's really what you have to look at. Again, this is where the nuances come in.
[00:09:49] Speaker B: Absolutely.
[00:09:50] Speaker C: It's not so clean as reading the DSM 5 and saying based on what it says the criteria is for this particular disorder, this is where this person falls. Because you then have all these other nuances that complicate things.
[00:10:06] Speaker B: Absolutely. Yeah. And you know, I think that we all, no matter what we've specialized in, have, have, you know, had that thought come up about clients wondering a little bit around this and when you know someone, what are some of the symptoms or signs that people or providers should be looking for, whether or not they are, you know, assessing them as a school counselor or a therapist that they're already seeing or even within a health setting? You know, certainly the nature of these disorders is that they can be secretive or the person maybe doesn't like kind of consider it a disorder. Right. Like especially with a healthy eating, sometimes there can be a sense of pride about it.
So what are some of the things as a clinician that we should be kind of monitoring and looking out for to assess for the severity and decide if it's something that needs attention?
[00:11:03] Speaker C: There are some symptoms that are probably easier to identify than others.
For people with eating disorders across the spectrum, whether it's on the malnutrition site for anorexia or the binge eating side for somebody who has a larger body mass, there's a couple of things. I'll come at it from a private practice perspective in getting to know the patient, what is it that is their concern?
And I begin to ask them about quality of life and are they able to do the things that they desire to do for a high quality of life. And that would be socially, physically, psychologically, all those categories. And if they begin to say, for example, that they have begun to restrict their social interactions because of something to do with the way that they consume food, right there you begin to identify we have a potential issue. And as they disclose whatever that information is, the ability to build a rapport with them. So that A, we're looking at it from a non judgmental perspective, B, looking at it from what is reasonable for somebody at their age, at their current position in life, at their current physical condition and then their personal desires. Are they missing out on something because of, or limited because of this issue with their food?
And so that's generally where I begin and would suggest somebody begin with. The next thing you look at is, and I'll go into more of the medical side just a little bit. When was the last time they had a physical? When did they see their primary care physician or their pediatrician? And if it's been a period of time and they have concerns and we can now Tie something to the way that they consume nutrition. I would make a referral and suggest that they go see their pediatrician, primary care physician, get complete workup, and let's start there to make sure physically they're sound.
[00:13:16] Speaker B: So if they're kind of acknowledging that, you know, there are some things happening for them and medically perhaps, you know, it's questionable as to what might be going on. It's appropriate to really encourage them to get checked out so that you have kind of some more data and understanding of where they fall kind of on the spectrum.
And you had mentioned isolation, like socially. Right. Are there other symptoms that should be considered in terms of red herons, perhaps that an eating disorder might be present in social settings?
[00:13:53] Speaker C: Yeah. For any counselor, do a review with their current life patterns, check out their sleep patterns, and are they sleeping reasonable amount of hours per night, Are they not? Are they waking too much? Are they getting to bed too late? Also begin to ask, what are your eating patterns? When do you have breakfast? Do you have breakfast? When do you have lunch? When do you have dinner? Do you have snacks in between? What are the size of those? Do they seem reasonable for what you're doing? And from there you begin to really get into their life to identify is their complaint somehow related to something that has changed within those categories? On the isolation piece, let's say, for example, somebody is malnourished and their sleep habits have now been affected because they're not, and they're not getting into REM sleep. The next thing, are you having headaches? Are you tired? Are you sleepy? Are you cranky? The common diagnoses that go along with eating disorders are pretty standard. You would have anxiety, a mood disorder, chemical dependency of some kind. Those are the three standards that you want to begin to assess for. And then you might also look within that spectrum. Do you have any genetic factors from the family? Any schizophrenia, bipolar disorder, major depressive disorders, Any other things that other thing that might complicate the matters and that be are beginning to show up?
So when you're assessing for this whole process, the question comes up, what came first? Was it the way that they manipulate their food, and now it's beginning to affect their pathology and their physiology? Or did they have a physical condition that has now contributed to starting the manipulation of their food? Or maybe their pathology for some reason has worsened under some condition and now it's starting to affect their ability to get proper nutrition. So it's all of these things you begin to look at, and it has their life changed dramatically in the last period of time and by diagnostic criteria it's usually 90 days.
But I would go back a year, maybe two to see has something dramatically shifted from when they were functioning in a more healthy or reasonable way.
[00:16:43] Speaker B: That sounds like a wonderful lead in as well into kind of discussing with the client why it's important to seek treatment. Right. To kind of describe some of the things that might be tied that perhaps they hadn't even made the connection between the ways that they may be physically feeling poorly or their social lives are struggling.
Because I think it's really challenging to get someone to agree to a type of treatment that is addressing a way that they've been coping unless they have buy in. So it sounds like bringing these things up and assessing for them creates an avenue for discussion around wow, wow, like maybe this isn't working for you like you thought it was. And look, look what, what, how it might be impacting you.
It's so helpful to learn. So if, if a therapist or you know, referring provider kind of is assessing is having this conversation and you know, from the answers that are given is realizing that a referral may be necessary.
Can you share a little bit about the different levels of care and kind of the structure within the eating disorder treatment world so that we can start to understand what type of referral is needed based on severity. But it probably be just great to start with a general kind of framework of the structure.
[00:18:05] Speaker C: Yeah. You know, leading into that in your first a description of what you just said, one of the things that pops up in order to move the direction of making a recommendation for a level of care is recognizing a key feature that almost all of our patients have that they don't want to face. And that's called shame.
And the reason I want to mention this is when we are young, we learn to feed ourselves effectively beginning between age 2 and 5 and we pretty well got it mastered by the time we're six. Now granted, we still need our parents and you know, caregivers to feed us. They provide the food, but we could feed ourselves.
The reason shame is key is when you have a 10 to 50 or 60 year old person that is struggling feeding themselves, it's a primitive process that they're experiencing. When I say primitive is when you can't feed yourself. It's a very young age dynamic. And because they are older, there's a lot of shame related to this.
And with that shame comes the at times resistance to hearing that they need more help than a counselor or more help than a doctor, because this is A much more significant issue. There's layers to it. And the reason I mention that is when you begin to make recommendations, the rapport between the clinician and the patient really needs to be established. Well, in the idea of trust. And when a referral is made, the patient will want to know, out of their own security, will you as a therapist or me as a therapist, be there for them through this process and. Or when the time is for them to return back to this level of care?
[00:20:11] Speaker B: Absolutely.
[00:20:13] Speaker C: Now.
[00:20:14] Speaker B: Right.
[00:20:15] Speaker C: Yeah. So anyway, do you have any thoughts on that before I go into the levels of care?
[00:20:18] Speaker B: Yeah, no, that. That's really important. And I was just thinking about autonomy right. During that stage of life, like learning to do things for yourself and.
And that's really challenging. And then having more and more professionals step into your life and start helping you makes you feel more and more like a child, probably. Right. So I can see how that dynamic with the shame can really get triggered.
So thank you for highlighting that. That need really to look at the sensitivity around the topic and understand where people are at and why it may be so challenging for them to open up or even to take feedback. Because, you know, I think we talk sometimes about like, client resistance. Right. But. And sometimes you'll hear people talk about it as if they're doing. They're doing something wrong. Right. Instead of addressing that something is happening internally for them and you kind of have to slow down the process and start to build a stronger connection and understand where they are in order to kind of help guide them in the direction that they need to go to heal.
[00:21:24] Speaker C: Yeah. So the way the key piece for me, when I begin to look at a higher level of care, or let's say adding to a level of care, because in an outpatient setting, if somebody is going to stay in an outpatient setting, more than a therapist is necessary, and that would be adding a psychiatrist, a primary care physician, a dietitian, a group therapy process, as an example.
The factor of a patient. There's two pieces here that would take into consideration too. This population struggles with what called. What is called a set shift dynamic. The set shift dynamic is they get set in their ways. And because they're set in their ways, they're relatively rooted in a pattern that they don't want to change.
And when a recommendation or potential recommendation for adding services or adding a level of care begins to occur, that's now going to require a change, and it's a dramatic change for this population, they're going to become unsettled. They're going to become mistrusting it. It's going to be very scary for them. And so A be aware of that and then B is I look for the locus of control under different dynamics.
And some would be when the patient is alone and there's no stress or in a social situation or with their family at a holiday meal, can this person adequately feed themselves in a sufficient way to sustain their quality of life in that level that they're at? If the answer is they cannot, then a higher level of care might be necessary because they're not getting proper nutrition.
Compound that with if you're not getting proper nutrition, most likely they're getting isolated. Most likely they're also starting to having some medical conditions, medical complications.
The levels of care start with I'll start at the highest level. And this is where it gets.
The requirement for medical oversight is absolutely the key to keep them alive. So the highest level of care is inpatient medical, inpatient, psychiatric. And the purpose of inpatient medical and inpatient psychiatric is to move the patient from being a danger to themselves or a danger to others to a position of not being a danger to themselves and not being a danger to others. When I say a danger to self on a medical standpoint, it's that their body has decompensated to a point that their life is at risk.
Pretty simple.
And you need medical care to do that. So a hospital, if it's psychiatric because you have significant self harm suicidal ideation, which is not unusual for this population, well, they need the inpatient psych stabilization process. Now at the inpatient level of care in both of those, it is a short duration generally. And once they're stable, they're going to have to move to the next level of care.
And it's really up to the medical team to determine what stabilized means. And we'll just leave it at that because both of those have their own criteria and based on their center, so that's inpatient. Your next level of care is like what we do here at Hidden river is residential level of care. Now residential level of care is quite unique. It's 24 hours of care, seven days a week for a period of time. And it varies based on a person's medical and psychiatric stability.
The real purpose of residential care is that I'll say it's threefold. One is keep a patient stable enough to not have to go to an inpatient level of care. So we don't want them to go to a higher level of care and then prepare them to move to a lower Level of care.
And that's really it. And what's the key to that? That the person, when they come in, they're coming in because they cannot adequately feed themselves in a reasonable way to sustain a high quality of life, to move to a lower level of care.
So it really is that nutrition piece and that self ability to consume food, period.
Now within the residential care, we're also going to deal with the medical conditions that they might have and the psychological conditions that they might have that are preventing them from being able to consume reasonable and proper nutrition.
And over the stay. That's what's going to be addressed by a dietitian, a therapist, group therapy, nurses, doctors, psychiatrists, everybody is there, part of that process to make sure that we get the patient through there. Once they're able to adequately feed themselves, then they will move to what's called a partial hospital level of care. Partial hospital level of care is that they would reside at home now and they'll sleep at home seven days a week. They would go to a partial hospital program probably up to five days a week, and those are generally five to six hours per day, which means that the person would be dedicated to that program. They wouldn't be going to school or they wouldn't be going to their regular school and or they wouldn't be going to their regular place of employment if that were the case. But they would have evenings and weekends and at that level of care they would be receiving generally a lunch and maybe a dinner and snacks. At that level of care, they might get breakfast. It kind of varies, but the reality is they would have to feed themselves at least one meal per day at home over the weekdays and then all meals and all snacks on the weekends. That's partial hospital. Then there's intensive outpatient level of care. At an intensive outpatient level of care, a person would be attending school or their job and they would generally be going to program about three hours a day. At three hours a day they may do a meal there. Most likely they're only going to be doing a snack. At that level of care, Like a partial hospital level of care, you have therapists, you have dietitians, you have psychiatric oversight with a psychiatrist. Most likely they would be working with their pediatrician or their primary care physician as their medical professional provider. But they would have general oversight with all the other professions.
And then from IOP or intensive outpatient program. The next level of care is outpatient where they would work with a therapist on an outpatient basis weekly as needed. A dietitian See their pediatrician as needed and a psychiatrist as needed, probably once a month minimum. At that outpatient level of care, the patient is fully responsible to living their life in the way that they would choose that would be socially acceptable for their dynamic desire and family and goals. They would be responsible to feed themselves all meals and snacks and then talk with their team on their scheduled appointments.
There is another level of care that has really taken off since particularly 2020, and that's virtual treatment. And that type of program is that the patient would not see their providers, like their therapist or their dietitian, live in office type sessions. It would be virtual, like what we're doing here.
And for that, it would be similar to an outpatient program, at minimum, where they have a therapist and a dietitian scheduled per week and they do video conferencing. It could be a virtual IOP where they have anywhere up to 5, 3 hour sessions per week as they were going to a live iop instead they're doing it virtual. Those are the levels of care that a person could participate in.
[00:30:09] Speaker B: Okay, so I'm curious, for the virtual level of care, how do they handle things like weight checks or, you know, monitoring at meals and meal time and, you know, eating and things like that? Is that, how is that, how does that work out? Because I know some of that care for eating disorders can involve those kind of more hands on, checking progress with numbers and whatnot.
[00:30:31] Speaker C: Yeah, well, depends on the patient. But I'll just go through more of a common process that is done at the higher levels of care. When I say higher, inpatient and residentials most likely do it the this way, where they do what we call blind weights. The weights would be checked up to a daily basis by a nurse or a dietitian. That's recorded in the record, but they're done in such a manner that the patient does not see the weights. Now, the purpose for not showing them the weights is that the patients are already anxious and nervous. And if they're on the malnourished side and significantly emaciated, there's all the body image issues that begin to come up for them. And this is both males and females. It doesn't discriminate here. And part of the protection from the treatment team is it's not that they don't ever want to show the person that information, but the person has to be ready to absorb the information and stay on track with the treatment goals.
Yes, at a IOP level of care, it's sometimes at a residential level of care, but more Likely at a php, IOP and outpatient, the treatment providers at those levels would determine when is the right time or best time to begin to expose the patient to their weights.
[00:32:02] Speaker B: So this is fascinating. And you know, one of the things that I kept thinking about is how the levels of care seems so important in this specific area because of the nature of just kind of, I guess like a. Very similar to addictions, right, of kind of coming out of something and you know, having kind of the extra vulnerability of that process. And of course we see this in other mental health diagnoses as well. But when you were highlighting the shame and the, the, you know, autonomy and things around that issue, it made me really think about that dynamic that can happen within families. Especially, you know, when you're working with teens or younger adults where they start to lose some of their independence to their family or, you know, it's so upsetting to parents to see their child struggle in that way and in ways that are very physic, that manifest physically often. And so often the family can get activated and, and can kind of be in an adrenal rush of just trying to help, but in some ways can exacerbate symptoms right by the way that they're approaching it. And it can become a power struggle. So I'm really, you know, curious about how you think about the importance of looking at levels of care and kind of following kind of this step down model and how it relates to supporting them in like the transition back into their, like daily relationships and lives relationally.
[00:33:36] Speaker C: Well, you hit on a couple of key topics. One is how to help prepare somebody to make transition. But the other piece, you talk about families and this is a real challenge for anybody with an eating disorder and it's a challenge for their family. Having been a marriage and family therapist for many years and working very intimately with families, you get this dynamic that is a challenge for anybody to come to terms with that their loved one struggles with feeding themselves. It just baffles people and it truly is baffling. It's like, why can't you just do this? It's like Nike therapy. Just do it. It's simple, but it's not for them. And there's a physiological and a psychological process that prevents them from being able to consume from grease. That's a different topic. But let's go back to the families. The families need support. By the time they come in for treatment. Generally what's happening is they have tried a number of things to encourage, persuade, manipulate or force their child to eat or Love them. But they've done a number of different things, whatever that spectrum is for them, and they've not worked. If anything it's ingrained the malnutrition or misuse of food process more into the person's behavior because now you've got that power struggle. And for a parent to lose a power struggle with a child is. It could be bad. And so parents come in, they're anxious, they're nervous, they're mad, they're upset, they're confused, they're. They're struck and they don't know what to do. The shame also for them is very high. And as a clinician, I always want to be sensitive to that is these people love each other and they're at their wits end on what to do. So how do we help them? Number one, as for the families, they're part of the process of treatment and so is the individual that's coming in as the identified patient. Everybody needs education, everybody needs to understand what's going on and they also will want and need, even they may not recognize it, how to communicate effectively without offending each other and driving the eating disorder to be more robust.
So for the patient, there's another area that a clinician really needs to know. There's this term called alexithymia.
And the reason this is important is that when patients come in, and I've seen this with young clinicians, I even did it myself, there's this common thing we want to ask. How do you feel about things?
And have you ever had a patient when you ask them a question, they give this blank look and it's kind of a clown face of.
And they give you a rope answer. Well, that's what happens. Here's what alexithymia is. When you ask somebody a feeling question, that's the wrong question. And here's why. Alexithymia is the inability to identify emotions in the context of the experience and the lack of terminology to express them in a productive way.
That's kind of my synopsis of it. And what you end up happening is you have a separation of physiology, so physical experience from psychology or thought processes and then a separation of the emotional experience of things so you have less triad that is all separated.
And for a patient, because they can't articulate from a physiological or an emotional standpoint these psychological, emotional questions, they're going to give you answers that make no sense and they're trying, but they don't have the terminology for them.
The other piece is with people who have eating disorders, they can be more highly ruminative than your average person. So their mind works faster. I'm not saying this is a good thing. Their mind works very rapidly. Their thoughts get ruminative and they get stuck in their thoughts. It's an obsessive process that goes on inside their head and then with that obsession, in order to stop it, they have some kind of a compulsion and they act out. So as a clinician, I want to be sensitive to, as I'm beginning to make these recommendations and or guide them is a. They are not adapt at integrating thoughts, physical experience and emotion.
And so I want to guide my questions and guide any type of recommendations and support to begin to unify those from a way that the patient can understand it. And then once they understand their current dynamic of what's occurring in their life and why they're doing what they're doing with food, why is it that now I'm going to make a recommendation for an additional therapeutic service or a different level of care?
So that whole process is very sensitive, but actually manageable if you understand what's going on.
[00:38:57] Speaker B: Absolutely, yeah. The kind of coming back to like, this isn't resistance. This is actually something that's happening for them within their brain and, you know, challenging and you have to kind of meet them where they are. James, thank you so much. This has been fascinating to talk about and learn about the different levels of care care, some of the signs and symptoms to look out for if we are working with someone, how to assess for eating disorders and you know, some of the, some of the ways that we can begin to talk about it.
This topic is so rich and so I would love to continue the conversation and start covering some other things. So we will have a part two coming up that covers things like the training and modalities within the eating disorder treatment realm and also working with families and how to support them.
So again, James, thank you so much and I look forward to continuing this discussion.
[00:39:54] Speaker C: Absolutely. Thank you.
[00:39:55] Speaker A: Anna, thank you for tuning in to the Art of the Referral podcast. We hope you found today's episode insightful and valuable. Don't forget to subscribe and leave a review to help us reach more providers and clinicians. Clinicians like you. Follow us on social media and visit our website for additional resources and updates on upcoming episodes. Until next time, keep mastering the art of referrals and making a difference in patient care.
[00:40:22] Speaker B: Goodbye.
