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 am 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 back to the Art of the Referral with James Runyan. Part 2. This topic around eating disorders was so fascinating, so much to cover, so we took what was supposed to be one episode and we broke it into two so that we could really do a deep dive. This second episode, we are going to be talking about treatment modalities within the eating disorder realm, the training that eating disorder therapists go through and what to look for in a reputable provider. And we're going to talk about interacting with family. Oftentimes we may not have someone on our caseload who has an eating disorder, but perhaps we have a loved one who's a caregiver.
The whole family system is very much important in all treatment of mental health, but specifically eating disorders. So we want to give proper time to addressing that so that you know how to support those family members.
Welcome back, James.
[00:02:03] Speaker C: Great to be back. Thanks, Anna.
[00:02:06] Speaker B: All right, so yeah, let's dive right in treatment modalities. Can you share a little about that and some of the ways that you approach the treatment of eating disorders?
[00:02:17] Speaker C: Right. To identify treatment validities really look at, okay, what diagnoses is somebody going to be treated?
The common issues that patients are going to present with, of course, are malnutrition, you're going to have anxiety, and on anxiety you have the spectrum of anxiety disorders. It'll not be unusual and it will be very common to have a generalized anxiety disorder and or obsessive compulsive disorders. And with obsessive compulsive disorders, you've got a number of other things. Things I've had everything from trichotillomania to don't step on the crack on the sidewalks, your traditional thing, to other fears. But it all associates with food to some extent as to what they're Coming in the office with then you have mood disorders, so major depressive disorders. You could have bipolar disorders and or just other depressive episodes.
We could have some psychotic processes coming on. So you have to be very familiar with when somebody become, begins to detach from reality because that will factor in here too.
So and then of course in the last episode I mentioned alexithymia, the inability to identify emotions according to experience and lacking the terminology to express them in a productive way. So you have that. So all of those will be compounded with some kind of. And it's not, I'll say it's at times diagnosed properly but can be over diagnosed. Trauma will have trauma related symptoms. You can have ptsd. So you have to be familiar with how to address that. And within the realm of trauma you want to begin to look at all right, what is this considered? The little T versus the big T. And not invalidate either one. But recognize the patient's experience is real and our job is to be able to assist them.
You might also have some spectrum related issues with sensory integration. I know those are two different things but oftentimes they're interrelated. If somebody has arfid, they might have some sensory integration related issues. So a neurological psychological workup for that to see is all right. There are other issues coming on her that are just more physiological based genetic, you're not going to get away from and there's a training. So then knowing all that information and then the other thing we need to know the person's current age, current developmental process, have they gone through all the proper developmental steps and processes up to their current age or did they miss something or get delayed in something because that all compounds in there.
Now let's move into modalities.
You can see why when we move into modalities there's a number of different modalities. There's some common ones that we will use but there's also a number of different ones based on the diagnosis and presentation.
So modalities, number one is from a residential care and I would say across the board every patient with an eating disorder needs. They need to have their primary care physician involved for a modality and to make sure physiologically they're sound and if they're not sound, what needs to be done. Number two, a registered dietitian, somebody who's gone through the process of training to be a registered dietitian is licensed and is adequately prepared to make medical orders for nutrition because they're in the medical field. It is an order from a dietitian to manage that for somebody based on their age and condition. Then the third thing is psychiatry, a psychiatrist for their modality. Because you're dealing with anxiety, depression at times we have some, maybe some psychotic features, delusional features going on. We might have other things, but let's just say it's depression and anxiety. We need a psychiatrist to give them the tool either on a temporary basis, on a temporary a year or two, or maybe longitudinally for many years to come. They're going to need some help from a psychiatric standpoint, medication standpoint to stabilize the obsessions or lift the mood that they themselves cannot do.
So those are the assistant to a therapy side for the modalities. Now as a therapist, this is where our training really comes in. We need to be very knowledgeable about all aspects of human growth and development from genetics to death, because we're going to be dealing with everything. And when somebody walks through our door at a current age and position of life, we want to see and understand are they making the journey through life reasonably compared to everybody else that we know is relatively healthy. Then training wise based on mood, anxiety, things like that. I highly encourage to know DBT dialectical behavioral therapy. Absolutely have the work that Marshall, Dr. Marshall Linehan has pioneered and used extensively. We use it almost across the board in most eating disorder programs. And it is very effective. CBT understand how to educate people on based on their age and their understanding the cognitive behavioral processes of what they're currently doing to what would be considered better for a better quality of life. That's what we have to really know CBT in the eating disorder realm, we need to also know trauma recovery and there's so many different ways to do that. Now I'm pretty old school, so there's a lot of really historic ways that I would use personally from talk therapy and experiential dynamics. I'm trained in psychodrama, so I use a lot of psychodramatic techniques in that and it's very effective. A lot of drawing, a lot of artwork, things like that. But we also have emdr, we have act, we have different modalities that are quite effective to help with the PTSD side of things and the trauma side of things. But with that said, again, leaving it to the experts in those realms to properly apply those things then in eating disorder realm when it comes to dealing with things, because your primary issue is going to be related to anxiety exposure response, prevention, therapy techniques, knowledge and how to set up a program for a patient is absolutely crucial. Now the reason for that is, I always say, you don't want to do Nike therapy with somebody who's really anxious. You can't just say, go out and do this and tackle it. We call that flooding. And when you flood somebody, you overwhelm them and you shut them down. And if they're prone to alexithymia, you're going to enhance the splits that I had talked about. And it's not going to do anybody any good. So an exposure response prevention program would assess whatever the related fear object or action or social event is and then begin to build a scale of exposure and slowly move a person through that process until such time that they can effectively get through, address, do whatever that highest anxiety event is, if that's appropriate. So exposure response prevention is key on a family therapy side any. Well, even on an individual site commute communication therapy. And I don't hear much about communication therapy much from folks anymore. But in my training, we did a lot of communication skills training, learning how to talk from an interpersonal level, integrating thoughts, emotions and behaviors and being able to articulate that, own it, but also have other parties give the individual room to have that opportunity.
That brings to me to the family. There is one dynamic that is common to families, and we've seen that in some of the research. But I've also experienced. Experienced it very much. And it's not because anybody's doing anything wrong. I want to say this up front, but it is a natural process, I think, to the human condition.
But the word that we often see, and I'll put it is called invalidation, is that the patients themselves feel, perceive or experience that. Their thoughts, their emotions, their. Their physical presentation, something about them as a person is invalidated in the family communication process.
And the reason communication is so key, because as a clinician, I have to look for those things that are dismissive of the patient's position, process and condition, because if they stay there, we're not going to help them get better. And then also look at the family process and the parents, because the parents are trying really hard, but obviously something's not working. They don't understand it. And if you bring up a process of communication where they're invalidating the patient, well, you better be really good at this because you're going to create a conflict with you and that parent. And you have to prepare everybody that our goal is that everybody has a voice and we really ultimately to hear the voice of the patient because she or he is the one that is the most suffering in this moment and also the most at risk for her or his life to be terminated if we don't get a handle on this. So going back, that communication process is critical.
[00:12:26] Speaker B: That makes a ton of sense. I was thinking a lot about how shame is kind of contagious, right?
As the person who has the eating disorder might feel the shame, certainly, especially parents can feel a lot of shame. But they, you know, one of the primary goals is to keep your child nourished, you know, and so no matter what age they are, that can bring up a lot of shame. And so helping a parent feel like they have the tools to communicate and effectively help their child is so important, important to the, to the well being of the system of the family.
Because it is such a helpless feeling to want to help and see someone struggling and feel like everything that you do is not working or is creating more conflict. So it's kind of helping set them up for success, it sounds like.
[00:13:19] Speaker C: Right? No, yeah, that's right on. You have a whole spectrum of family dynamics, and I've seen this a lot.
Common to people with eating disorder, particularly anorexia and bulimia, is what I call high performance. They're high performers, either academically, athletically, socially, somehow, and the family themselves are high performers. And there's this expectation that everybody's always going to be a high performer and be successful. But sometimes that expectation of performance is either in conflict with the heart, soul and mind of the patient, or the expectation is so high it's just not achievable at their age and position in life. So either way, it's an invalidation process. And is it wrong? Well, maybe not by concept, but by application it's doing harm. And as a therapist helping a parent look at that. When the parents coming and saying, well, we just want the best for a child. Well, yeah, I get that. That makes total sense. Yet your child is not ready for that level of pressure. And the comeback from parents sometimes is, well, we're not putting pressure, we don't ever say anything about this. Yet the patient puts the pressure on themselves because they understand their family dynamic on a intuitive level perhaps and a perceptive level. And they're pushing themselves in such a manner that is beginning to break themselves down and they don't know how to stop.
So it's this whole confusing process to families.
[00:15:04] Speaker B: And I've noticed is that the personality traits that seem to be more prone to eating disorders are the people who are more sensitive and intuitive and pick up on the signals that aren't said. You know, those that kind of hold things Inwardly.
So getting them to communicate and share and talk about feelings is so important that it's positively reinforced and not accidentally shut down in the process. Again, because that's kind of sounds like it's part of the healing is finding.
[00:15:37] Speaker C: Other ways on the personality process. I'm glad you mentioned that. When I began as a kneading disorder clinician back in 1994, the clinic or the centers of residential care that I worked at, they did a battery of exams, and it was the mmpi, the Milan and house street person, all the old school stuff. And we really learned a lot about the traits of the people that we worked with. And then when I went private practice, it's like, well, I don't have the resources to do that in a private practice, but you can do the house street person. We can also do some other temperament and personality things. And here's over the next 10 years, that's what I did. I really studied temperament, personality. And there's common traits across the board that these patients will deal with regardless of their diagnosis and regardless of their gender. It's all the same. And on a temperament standpoint, they are very, very sensitive. And I want to say it's hypersensitive. It's not, oh, you're just a sensitive person. No, they're hypersensitive that everything is almost as if they have no protection on their nerve endings, and it goes through their sensory integration process, and it just traumatizes them. It's too intense. Then the sky's always falling. They're timid, and they don't know what to do because they're always afraid. And then they think they're the problem because they're so different than everybody else. They're overly sensitive and they don't know how to handle things, and so they keep it to themselves. They don't tell anybody. And then if they were to tell somebody, they don't have the vocabulary for it because they have alexithymia. So it's a double whammy.
Then what they do is they start to take it out on themselves and braid and be derogatory and just absolutely cruel to themselves in their head and or in their body. They will harm themselves. And folks might say, well, that's just crazy. Why are you doing that? It's all an impulsive process. The pressure builds up in their body. They don't know how to get rid of the pressure, so they do some kind of harm. And that harm could be cutting, could be running, could be hitting a tree, could be exercising. It could Be vomiting, it could be overeating, could be under eating, whatever. And it triggers the endorphins of their body to soothe themselves. So that's all the temperament process that's going on. Personality, there's two factors. One is, I call them the caregivers of the world. Everything in the world that is of compassion and sensitivity and harm, they absorb it and they don't know how to distinguish themselves from others. And so if they see something on TV that harms another human being, it just crushes them and they don't know how to have that boundary. The other real strong component of people is that they are traditionalists. They want to hold on. Tradition, their struggles. They don't know how to change. So as life goes on and they grow, you gotta adapt. They don't. And so we need to understand, we have the compassion people that don't know how to set boundaries with things that are not of them, and we have the other people that don't know how to adapt and change, and they get stuck. And underneath that, you have that temperament process that they are just overly sensitive and they're shutting down.
So it.
It's just important to understand we're dealing with human beings that are, I would say, on the bell curve. They're on the other end of the bell curve. They're not in the center of the bell curve. They're like normal people, and yet they want to be normal and we want them to be normal. And I'll say they're abnormal. They just have these unique traits, right?
[00:19:22] Speaker B: And traits that sometimes might seem like they contradict one another or like some, like, ambivalence or things that kind of work against each other. So it really does make sense why this can be such a challenging thing to treat unless you really understand the depth of it and know how to hold both and kind of meet someone where they are and understand the different mechanics of what might be going on.
This is so helpful to learn about. And gosh, I could probably do five more of these, I think, on eating disorders alone and still just feel like we touched the surface. But I really think that this was just incredibly insightful for people who might be interacting or working with either family members or people who have eating disorders. And in the show notes, I'm going to include some of the resources that you share that can be helpful if people want to learn more. But before we end, James, I want. I wanted to ask if there's anything else that you would like to share about where people can find more information about the work that you do or any opportunities that may arise from learning more from you and your organization.
[00:20:34] Speaker C: Yeah, there's a couple of things that just great resources for any clinician for a questionnaire if you're in an office and you want to identify some avenues or there's the scoff S C O F F. Just Google scoff. And then there's the esp. Those are both simple questionnaires to give a patient.
Then googling in the eating disorder. There's eating disorder professionals in the around the country and around the world and I'm one of them. It's called a certified eating disorder specialist. The organization that we get our certification through is called iodep, International association of Eating Disorder Professionals. And in order to get that credential you got to do a lot of work. Number one is there's four classes to take and there there's a general overview, there's medical, there's nutrition and then there's clinical. Real important. Then they have some exams to take and then you have supervision. Find an age disorder professional who will oversee your clinical work for about 2,000 hours and it's absolutely worth it. And there's some of the most wonderful professionals to work with, been involved with for 30 years, absolutely adore this. These people, all of us, I mean they're all great people. Then when you're looking at levels of care, you want to look for people that know eating disorder work and provide excellent oversight with well trained staff. So for example, here at Hidden river, part of the expectation of anybody we hire of any professional discipline, everybody goes through the IDEP courses and we also give them or get them supervision. They're on track to being certified eating store specialists. Our clinical director is a certified supervisor. I'm a clinical supervisor for that category. And then right now all of our staff nurses, dietitians, therapists, have gone through the courses and are under supervision. And many of them are close to finishing.
So you have that.
[00:22:33] Speaker B: What a benefit. What a benefit of working.
[00:22:36] Speaker C: Yeah, it's a lot of work. And then IDEP has chapters around the country. If one's in your region, join them. They do quarterly events and trainings, education and get togethers. They really want every discipline to network, be colleagues together so we can provide levels of care. And at Hidden river, Of course, we're residential 24 7, seven days a week. We follow the APA guidelines of 2006 to 2000, team very, very well. I monitor those things very closely every day. Every patient, we keep them for the length of time they qualify. But once they don't qualify. We're moving them along to the next level of care. But we know so many professionals around the country. We connect people with eating disorder professionals and we try to stay in that realm. But if not, that's where virtual comes in.
And I think, if anything, in the eating disorder treatment profession, what I've experienced is professionals across the board, every discipline, they're very protective of their patients. They want the best for them, but they also know how hard this work is, and they know the risks if we don't provide it to the individual and the family. And the commitment to that family is absolutely key. And they refer within the eating disorder professional realm as much as possible. So I would encourage folks to get involved with that.
[00:24:00] Speaker B: I love to hear that. Yeah, it's so important that professional collaboration is so important to the work we do, both in our own ability to thrive in our careers without burning out so that we have people to rely on and also for the people seeking treatment. And, yeah, from talking about this, it's easy to see how this can happen and unfold very quickly. Someone can seem okay and then in a very short time can not be okay. And, you know, we want to avoid a situation where someone has to be hospitalized. So wonderful to know about this. And arm people and therapists with the knowledge so that if you start to notice things, you can assess and step in and offer support so that it doesn't get to an extreme level and that you have the information to know that there are people out there and there are supports out there that are well trained. And now hopefully, you know what to look for. So you're not so reluctant. Because I think we can all be a little protective of our patients and scared about, you know, passing them along unless we have a sense of security or knowledge that we're doing the right thing and sending them to the right facility or person. So thank you so much, James. Such a pleasure. I have a feeling that I'll be having you back on soon, if you'll. If you'll be willing, because it's. It's. There's a lot to cover here, but appreciate it.
[00:25:20] Speaker C: You're welcome. It's a pleasure. Anna. Thank you so much.
[00:25:24] Speaker B: Thank you.
[00:25:25] Speaker A: 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 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. Goodbye.
