Tips for Addressing "Goal Weight" with Patients

by Tara Deliberto, PhD

In the treatment of anorexia nervosa / atypical anorexia nervosa (i.e. “AN Disorders” is IMT), it is important to mindfully address the topic of “goal weight,” the weight at which the medical doctor predicts a patient will be healthy. Although knowing a given patient’s “goal weight” is helpful for the treatment team, I have found this is less constructive for patients for several reasons discussed here.

When one particular number is provided to the patient (e.g. 100lbs), the patient can rigidly adhere to that weight as the only weight at which they can be. As such, even one ounce above that weight could trigger a relapse of eating disorder behavior. Of course, no one person can maintain their weight at exactly the same number throughout their life. This is particularly true for adolescents who are growing and will need to psychologically accept different numbers throughout their lifetime. It is also often the case that the goal weight provided is too low of a weight at which for the patient’s body to function healthily. Further, from a psychological perspective, it is more adaptive to foster cognitive flexibility and the tolerance of uncertainty.

As such, rather than tailoring the treatment towards the achievement of a specific weight, I provide about a 10-15lb weight range.  The lowest number in that range is typically the number that the MD defines at the "goal weight."  I frame what the MD terms "goal weight" to patients as the lowest weight at which their body is likely to be healthy.  For instance, if an MD says that an adolescent patient's "goal weight" is 100lbs, I might say to the patient:

"The weight range we are currently aiming at in treatment is approximately 100-110lbs.  This is because 100lbs is likely the minimum weight at which your body is to be healthy.  That said, once your body is 100lbs, we will need to reassess how healthy your body actually is at that time.  Also, it is impossible for your body to stay at exactly 100lbs forever.  For one thing, you are growing and you are going to need to gain more weight as you get older.  Additionally, your weight will always fluctuate within a weight range because it's impossible to keep your body at exactly the same weight every moment of the day.  For all of these reasons, we can only estimate that your weight will need to fall within the 100-110lb range to be healthy."

If the patient protests and/or demands one specific number, I might state that "the truth of what is healthy for a patient is not up for negotiation."  Clinicians are only in the business of accurately reflecting the truth, not forcing it to fit the demands of the eating disorder; and the truth of the matter is that a "goal weight" is an estimate, patients often need to gain more weight to be healthy, and their weight will fall within a range at any given time.  If the person cannot help but be driven by the eating disorder to negotiate, simply move the conversation onto the next important clinical topic. 

Thanks for reading! Please feel free to leave any questions and comments below.

When Are Blind Weights Helpful in the Treatment of Eating Disorders?

Most clinicians have heard that it is “better” to not tell patients with eatings disorders their weight. Although taking blind weights can be helpful, the decision whether or not to tell a patient their weight is actually context dependent.  Sometimes it is helpful and other times it is harmful.  Here we will discuss these conditions and how to approach disclosing weekly weights to patients.

Thinking of learning weekly weights as an exposure exercise often helps clarify the decision whether or not to tell a patient their weight.  After all, for many patients in eating disorder treatment, being told their current weight by a treatment team member triggers intense negative emotions such as anxiety. As in making the decision to start any exposure therapy exercise, the therapist much assess 1) the patient's readiness, 2) current skillfulness in tolerating negative emotions, and 3) likelihood of engaging in safety behaviors.  In this case, a therapist needs to make sure that a patient is 1) willing to be told their weight once per week, 2) has the ability to report the intensity of their emotions on a scale of 0-10, and 3) has agreed not to engage in eating disorder safety behaviors (e.g. restricting and purging) in response to the negative emotions triggered by knowing their weekly weight.  

Particularly early on in treatment, disclosing a weekly weight can cause very intense negative emotions (e.g. anxiety) at a time when they do not yet have skills to regulate those emotions.  As such, eating disorder safety behaviors (e.g. restricting meals, purging, etc.) may occur.  Since the most important goal early on in treatment is to decrease eating disorders behaviors (to foster medical stability), anything that gets in the way of that goal should be tabled for later in the recovery process.  Always remember that from a patient-safety perspective, the focus of treatment must be on what will most immediately foster medical stability (i.e. decreasing eating disorder behaviors and increasing recovery behaviors).  Before more nuanced emotional tolerance skills (e.g. tolerating the anxiety that comes with knowing one's weight) are able to introduced, a stable behavioral pattern must first be established.

Further, from a psychological perspective, exposure therapy is not effective when safety behaviors are performed.  If a patient effectively avoids the negative emotions that come with knowing one's weight by engaging in safety behaviors (e.g. skipping the next meal), it is the eating disorder behavior that is reinforced, not the skill of tolerating negative emotions.  In other words, the exposure therapy exercise is not effective because the result is the patient becoming more reliant on eating disorder behaviors rather than skills.  As such, we only want to employ exposure therapy exercises like disclosing weekly weights when the patient is willing and able, so that eating disorder behaviors do not increase and emotional tolerance is learned. In short, if the patient is not willing and/or able to know their weekly weight, then it is better from both a medical and psychological perspective to simply take blind weights once per week.

Although some patients may not be willing and able to know their weekly weights, others are! If so, then a weekly exposure therapy exercise can be set up.  In this case, the therapist asks how intensely the patient is experiencing negative emotions on a scale of 0-10 right before the patient learns their weight as well as after.  The therapist then sits with the patient until the negative emotions and any urges to engage in eating disorder safety behaviors goes down.

Here is a brief assessment that can be used in determining if a patient should be told their weekly weight:

• Is the patient willing to be told their weekly weight as an exposure exercises?

• Does the patient have a low to moderate (not extremely high) amount of anxiety about their weight?

• Is the patient is likely to use skills to manage negative emotions triggered by knowing their weight (instead of engaging in intolerance behaviors such as restricting or purging)?

If the answer to all three of these questions are “yes,” then it is likely appropriate to attempt disclosing weekly weights to patients as an exposure exercise. If the answer to any of these questions is “no” then use blind weights.

Hopefully this clarifies the process of determining whether or not to employ blind weights with a patient! Please feel free to leave any questions and comments below.

Is Group Therapy for Eating Disorders a Bad Idea?

Question: Is group therapy for eating disorders a bad idea?

Answer: Particularly in the treatment of adolescents, group therapy can be iatrogenic due to “peer aggregation,” the process of gathering information that can be used towards a harmful or self-destructive end (e.g. Dishon, McCord, & Poulin, 1999).  For instance, in the context of group treatment of eating disorders, adolescents may aggregate new information about diets and methods of purging.  

That said, pretty much all therapy at higher levels of care is conducted in group format and there are data to show that people do improve at higher levels of care.  [Whether or not this is due to group therapy or the structure of the programs is unclear. I’m not aware of any component analyses that examine which aspects of treatment at higher levels of care are predictive of symptom amelioration or are iatrogenic.]  Speaking from clinical experience, however, I would say that potential iatrogenic effects of group therapy for eating disorders can be largely mitigated by the leader.

For instance, group leaders can:

1. establish group rules (e.g. no discussing specific ED behaviors, no socialization outside of group, etc.) 

2. effectively redirect eating disorder behaviors (e.g. isometric exercises) in session

3. redirect patients if triggering language is used (e.g. "I lost 15 lbs by cutting out carbs")

4. to run the group like a class in learning specific skills (rather than a process group)

See attached for some guidelines on running ED groups from the IMT manual, Treating Eating Disorders in Adolescents!

Referring People with Eating Disorders to a Higher Level of Care

Even among advanced eating disorder specialists, there is confusion about what an appropriate level of care is for a given patient. This article aims to help elucidate the referral process with information from the American Psychiatric Association’s Practice Guidelines (Yager, et al., 2006) as well as my own clinical experience.

- Tara Deliberto, PhD

The Importance of Medical Clearance for All Eating Disorders 

When working with people who do not have eating disorders, making a judgment call regarding which level of care is required can be made with a thorough verbal and/or self-report assessment by a licensed therapist.  This is not the case with eating disorders!  Because eating disorder behaviors impact the physical health of a patient, you cannot determine the level of care – whether it be medical hospitalization, psychiatric inpatient, residential, partial hospitalization program (PHP), day treatment, intensive outpatient program (IOP), or outpatient –  simply by talking to or looking at a patient with an eating disorder.  Self-report measures don’t cut it either.  We therapists need to collaborate with colleagues in other disciplines, specifically medicine.  As a therapist, think of yourself as a project manager: your job is to help keep a patient and their carers accountable for health, but it is not your job to determine how often a patient needs medical examination, nor to interpret the results of one.  A medical doctor needs to collect information such as lab work, an EKG, and a physical exam before a determination regarding level of care is made.  Often a brief chat asking the doc to interpret the results is required before treatment at any level of care can commence.

Although it is not a therapist’s responsibility to determine if a person is medically at risk or not, therapist input about appropriate levels of psychiatric care (e.g. partial hospitalization program) is needed.  As such, you must communicate with the doctor to determine whether or not a given patient is appropriate for your practice.  If a given patient’s medical doctor is not familiar with the treatment of eating disorders, quickly send them practice guidelines for your country (e.g. the American Psychiatric Association’s [APA] Practice Guidelines; Yager, Devlin, Halmi, Herzog, Mitchell, Power, et al., 2006). It may also be helpful to provide the patient’s medical doctor with a copy of the AED’s Medical Care Standards Guide (available at www.AEDweb.org).  With an ability to communicate about the specifics of the practice guidelines as they relate to the results of the patient’s tests, appropriate decisions can be made.  

 Prior to scheduling an evaluation to be considered for our program, we require that a potential patient send us the results of the following:

-        A medical examination

-        An EKG

-        The following laboratory tests conducted:

o    CBC

o    CMP

o    Amylase

o    Magnesium

o    B12

o    TSH

o    HCG

o    Cholesterol (not fasting)

Although you may not be trained to read the results of these tests, you should facilitate a discussion with the medical doctor in which they are reviewed in relation to the level of care guidelines.  For instance, although you may not know what all of the medical implications are if potassium, phosphorous, and magnesium are low, you do know that these are criteria for medical hospitalization from reading the guidelines.  This should be discussed with the medical doctor and a treatment recommendation made with their input.

Tip: Facilitate Investigation of Potential Medical Symptoms Rather than Avoiding

There is an easy way to know if a patient is at medical risk or not: send them to a medical doctor!  It is a tragedy for patients with eating disorders that fearful therapists turn them away due to blanket concerns about medical illness.  Rather than turning away from treating people who may be medically ill, encourage investigation of potential medical illness.  

Referring to an Appropriate Level of Care

In the United States, we use the APA’s Practice Guidelines (Yager, et al., 2006), parts of which are included below to inform level of care.  Although excerpts of these guidelines are quoted below, it is highly recommended that the entire guidelines are downloaded from www.psych.org and reviewed.  Please note that the numbers listed below are for children/adolescents and numbers are different for adults.

Inpatient Hospitalization Level of Care

Child or adolescent patients who meet any of the criteria that will be listed below should be referred to an inpatient of care.  Please note that adult patients have a different set of medical criteria than children and adolescents.  Relatively, adults have a greater number of medical issues that are cause for inpatient hospitalization (e.g. glucose <60 mg/dl, poorly controlled diabetes, temperature <97.0 degrees Fahrenheit, dehydration, organ compromise, etc.) than children and adolescents.

 Below are some of the criteria listed in the APA Practice Guidelines for the inpatient hospitalization of children and adolescents, regarding eating disorders:

• Medically:

  • Heart rate near 40 bpm

  • Blood pressure <80/50 mmHg

  • Electrolyte imbalances, specifically:

    • Low potassium (i.e. Hypokalemia)

    • Low phosphorous (i.e. hypophosphatemia)

    • Low magnesium (i.e. hypomagnesemia)

  • Orthostatic blood pressure changes

    • (>20 bpm increase in heart rate or >10 mmHg to 22 mmHg drop)

• Weight Percentage:

  • Generally <85% of healthy body weight

    • Notes:

      • This translates to a BMi of around 16.7

      • This only applies diagnoses specifically of either AN and ARFID

  • Acute weight decline with food refusal, even if not <85% of healthy body weight

    • e.g. as in AAN

  • If the person has BN, BED, AAN, or OSFED body weight criteria do not apply

• Behaviorally:

  • “Unable to control multiple daily episodes of purging that are severe, persistent, and disabling”

    • “despite appropriate trials of outpatient care, even if routine laboratory test results reveal no obvious metabolic abnormalities”

  • “Needs supervision during and after all meals” as well as snacks

  • Needs supervision in the bathroom

    • Please note that if one does not have personal experience working with people who have extremely severe eating disorders this may seem an invasion of privacy; however, having working in inpatient settings it is perhaps the number one behavioral intervention that can reduce the dangerous behavior of purging. In the context of reduced purging behaviors, this ultimately helps to restore a person’s autonomy.

  • “Needs supervision during and after all meals”

  • Requires nasogastric feeding (e.g. feeding through a tube)

• “Motivation to recover”

  • “Very poor motivation”

  • “Patient uncooperative with treatment”

  • Patient is compliant with treatment only in a “highly structured environment”

Tip: Hospitalization on a Psychiatric vs Medical Unit Depends on the Local Resources

Whether a patient requiring hospitalization goes to a psychiatric or medical inpatient unit can largely depend on the resources available in your area.  Each individual unit is able to accommodate different medical needs.  For instance, a particularly psychiatric inpatient unit specializing in eating disorders may not be able to address low potassium (i.e. hypophosphatemia) through an intravenous potassium infusion.  As such, a patient with hypophosphatemia may require treatment on an inpatient unit at a medical hospital prior to being discharged to a relatively lower level of care such as an inpatient psychiatric unit or residential treatment setting.  The hospitals should know if they can accommodate the patient or not based on the patient’s medical records.  This determination is made by having the results of a patient’s medical examination (e.g. lab work, EKG, doctor’s report, etc.) sent to a given psychiatric setting for review.  Someone there should be able to provide information about whether or not that psychiatric setting has the resources and capacity to treat the patient.  If not, the patient may require medical care.

 Residential Level of Care

For patients that do not have medical and psychiatric symptoms severe enough for inpatient hospitalization but who still have eating disorders on the severe end of the spectrum, residential treatment may be required.  Unlike inpatient hospitalization which occurs in the context of a medical or psychiatric hospital, residential treatment is often conducted by professionals in a house where patients stay for a period of time (e.g. 6-8 weeks).  Residential treatment for eating disorders is conceptually similar to “going to rehab” for a drug or alcohol addiction.

Below are some of the criteria listed in the APA Practice Guidelines for referring children and adolescents with eating disorders to a residential level of care:

• Medically

  • Deemed medically stable for residential and does not require an inpatient setting

  • According to the APA Guidelines: “Intravenous fluid, nasogastric tube feedings, or multiple laboratory daily tests are not needed.”

• Weight Percentage

  • Generally <85% of healthy weight

    • Note: this only applies diagnoses specifically of either AN and ARFID

    • If the person has BN, BED, AAN, or OSFED body weight criteria do not apply

• Behaviorally:

  • Can implement the skill of asking for help from others in the environment

  • Can implement skills to inhibit purging behaviors

  • Patient requires supervision at meal and snack times

• “Motivation to Recover”

  • “poor-to-fair” motivation

  • In the context of treatment in a structured environment, patient is compliant

Partial Hospitalization Program (PHP) or Day Treatment Level of Care

If inpatient or residential treatment is not necessary, a patient may require treatment at a “partial hospitalization program” (i.e. PHP) or “day treatment” level of care.  Although some programs are run through hospitals while others are run through private treatment centers, they share the commonalities of: multiple hours per day of treatment with a multidisciplinary team.  At this level of care, patients go in for treatment during the day and sleep elsewhere (e.g. at home) at night.  Each program will have different hours.  For example, the specific PHP program at NewYork-Presbyterian Hospital that Dr. Deliberto established in 2016 for adults currently runs from 8:15am until 3:00pm, Monday through Friday.  PHPs and day treatment programs for eating disorders have multidisciplinary teams with members from the disciplines of social work, psychiatry, as well as nutrition, and oftentimes psychology, pastoral care, art therapy, rehabilitation counseling, etc.  Within the context of working together in concert to stabilize acute eating disorder behaviors at this level of care, professionals from each discipline contributes a tremendous amount to holistically treating the patient during each treatment day.

Below are some of the criteria listed in the APA Practice Guidelines for referring children and adolescents with eating disorders to a PHP or day treatment level of care:

• Medically

  • “Patient must be medically stable to the extent that more extensive medical monitoring as defined for [inpatient and residential treatment] is not required”

• Weight Percentage

  • Generally >80% of healthy body weight

    • Note: this only applies diagnoses specifically of either AN and ARFID

    • If the person has BN, BED, AAN, or OSFED body weight criteria do not apply

• Behaviorally:

  • Needs some structure

• “Motivation to recover”

  • “Partial motivation”

  • Cooperative

 Intensive Outpatient Program (IOP) Level of Care

An intensive outpatient program (IOP) can be run through a hospital or private treatment setting.  At an IOP level of care, patients attend program for relatively fewer hours per week than at the PHP or day treatment level of care.  Some programs may offer IOP for a small number of hours a day (e.g. 2-3 hours) several days per week (e.g. 3-5) or a relatively greater number of hours per day (e.g. 5-6 hours) on fewer days per week (e.g. 2-3 days).

 Below are some of the criteria listed in the APA Practice Guidelines for referring children and adolescents with eating disorders to a PHP or day treatment level of care:

• Medically

  • “Patient must be medically stable to the extent that more extensive medical monitoring as defined for [inpatient and residential treatment] is not required”

• Weight Percentage

  • Generally >80% of healthy body weight

    • Note: this only applies diagnoses specifically of either AN and ARFID

    • If the person has BN, BED, AAN, or OSFED body weight criteria do not apply

• Behaviorally:

  • “Can greatly reduce incidents of purging in an unstructured setting”

  • “Some degree of structure is needed beyond self-control to prevent patient from compulsive exercising”

• “Motivation to recover”

  • “Fair motivation”

 Outpatient Level of Care

If you are going to be treating a patient at an outpatient level of care, it is important that they do not meet the medical and behavioral criteria for treatment at a higher level of care previously outlined.  Because only partial information was included from the APA Practice Guidelines here, it is important to obtain a copy yourself for reference.

 Below are criteria listed in the APA Practice Guidelines for treating children and adolescents with eating disorders at an outpatient level of care:

• Medically

  • “Patient must be medically stable to the extent that more extensive medical monitoring as defined for [inpatient and residential treatment] is not required”

• Weight Percentage

  • Generally >85% of healthy body weight

    • Note: this only applies diagnoses specifically of either AN and ARFID

    • If the person has BN, BED, AAN, or OSFED body weight criteria do not apply

• Behaviorally:

  • “Can greatly reduce incidents of purging in an unstructured setting”

  • “Can manage compulsive exercising through self-control”

    • This criterion likely references outpatient individual therapy for youth

    • In our clinical experience, outpatient treatment is also acceptable for medically stable children and adolescents who have behaviors that can be managed by willing and able carers at home

• “Motivation to recover”

  • “Fair-to-good” motivation

    • In our clinical experience, child and adolescent patients with poor motivation can still sometimes be treated in an outpatient setting with family interventions if carers are highly motivated, willing, and able to participate in treatment

 Tip: Do Not See Potentially Ill Patients Who Refuse Medical Investigation

If, for whatever reason, your patient refuses to be medically evaluated or their carers do not bring them to appointments, the implications must be directly discussed in session.  If you do not have information about medical risk and the ability to discuss this with a medical doctor, it is likely wise not to continue with treatment.  As such, treatment may need to be terminated or put on hold until the appropriate information is obtained.  The exception to this is when treating BED in which there is currently no evidence for the presence of intolerance behaviors (e.g. the patient is motivated, forthcoming, etc.).  As will be discussed below, however, intolerance behaviors covertly occurring can be identified upon medical examination in cases that present as BED, but are more accurately either BN or OSFED. <end tip>

Ongoing Medical Management in Treatment

Once the appropriate level of care is ascertained, the frequency of ongoing medical assessment will need to be determined by the medical doctor’s a given patient’s treatment team.  If the patient is cleared for outpatient treatment, the patient’s pediatrician is part of the treatment team with you.  The same goes for any psychiatrists or dietitians the patient with whom the patient may be working.  As such, each individual patient may have a unique treatment team.  Regarding the frequency of medical assessment, the medical doctor on the patient’s treatment team will determine this.  

 Although deferring to the medical doctor for frequency of visits is always recommended, it is often necessary to introduce the idea of ongoing medical management throughout the course of eating disorder therapy to the patient/family.  If the medical doctor is not familiar with the treatment of eating disorders, this concept may need to be introduced to them before they determine the frequency of the visits.  Again, we must develop a level of trust in medical doctors and their ability to contribute to the team. 

Because it is the medical doctor’s job to make recommendations regarding the frequency of medical visits needed for each individual patient, only examples of the types of medical management that may recommended for various disorders are provided here:

• Binge Eating Disorder (BED): On intake, a medical examination with lab work is often necessary to rule out purging (e.g. based on amylase levels). Ongoing medical management of BED can be required relatively infrequently in comparison to other eating disorders, unless physical symptoms (e.g. acid reflux, diabetes, etc.) are present.

• Bulimia Nervosa (BN) and OSFEDx (OSFED without Atypical Anorexia Nervosa [AAN]): The frequency of medical examinations and lab work varies depending on symptom severity. A general rule of thumb – as an example – is every several weeks. Patients with BN or OSFEDx may also be required to see specialists (e.g. gastroenterologists).

• Anorexia Nervosa (AN) and Atypical AN (AAN): In the treatment of AN and many cases of AAN, patients often are required to have medical examinations and lab work taken at a higher frequency of about once per week or biweekly. Patients with AN or AAN may also be required to see specialists (e.g. cardiologists, endocrinologists, etc.).

Dangerous Behaviors to Note

In addition to common eating disorder behaviors (e.g. purging, compulsive exercise while dehydrated, etc.) being quite dangerous, there are some behaviors that may be particularly perilous worth mentioning here.

Although this is by no means a comprehensive list, note the following may be particularly perilous:

• If a patient is purging right after taking psychiatric medications, the medication might be coming up and not getting absorbed in consistent doses.

• Patients can be drinking alcohol and/or using drugs in addition to purging, which can result in electrolyte imbalances.

• Patients at any weight can be restricting water and fluid intakes, which can be particularly dangerous.

• Patients who are engaging in various combinations of the following behaviors may be particularly at risk of dehydration: restricting fluid intake, purging, abusing laxatives, engaging in compulsive exercise, and abusing alcohol.

• Patients who are underweight can have any number of electrolyte imbalances at any time.

• Patients who are not underweight but who are engaging in behaviors are also at risk for electrolyte imbalances.

• For patients who have severely restricted – especially those who have not eaten for many days in a row – there is a risk for refeeding syndrome. A non-medical way of describing this is the body “going into shock” after eating for the first time after a period of starvation. Refeeding syndrome could lead to a heart attack, stroke, coma, or death. As such, it is required that a patient be medically cleared before starting treatment and continued to be monitored.

Why Lab Work Is Helpful in Therapy

If a patient is purging, getting lab work can be very useful.  It is always best to consult with a medical professional regarding the interpretation of lab results.  At the same time, a non-medical therapist can learn the basics.  For instance, amylase levels can be in the elevated when the patient is purging.  Sometimes, however, the patient can be purging and the level is not elevated or the patient is not purging and it is elevated.  This is why it is best to consult with a licensed medical professional!  Regardless of occasional ambiguity, results can still be clinically helpful.  For instance, if your patient denies ever having intentionally purged, however, lab results are starting to come back week after week with increased amylase levels, you might suspect purging.  Confronting the patient on this issue may bring about disclosure of the behaviors.  On occasion, we have had patients at higher levels of care with a co-morbid BPD who reported purging but amylase levels were not elevated.  Having lab reports to objectively back up the team’s assessments that eating disorder behaviors were not being engaged in has also been clinically useful.

Helping Someone with an Eating Disorder Break Habits in IMT

Question: How can others in the patient’s environment (e.g. staff / family) interrupt patterns of eating disorder behavior?

Answer: There are many things that others (i.e. staff members, family members, loved ones, carers, etc.) can do to interrupt eating disorder behaviors and disrupt the maladaptive habit circuit.  In IMT we use the term "Reinforcement Impeding Behaviors" or RIBs to refer to any action that staff/carers take to prevent eating disorder behavior from occurring.  In other words, a non-enabling behavior.  And example of an RIB is preventing a patient from using the restroom within an hour after eating.  Alternatively, a "Reinforcement Allowing Behavior" or "RAB" is something that staff/carers do to enable the eating disorder.  IMT makes efforts to educate carers on what these types of behaviors are and how to prevent them.

Experiential Avoidance and IMT for Eating Disorders

Experiential Avoidance and Integrative Modalities Therapy (IMT) for Eating Disorders

Question: What are patients in IMT taught about combatting emotional / experiential avoidance?

Here's the response: There are a large number of skills taught over time to patients to address avoidance in IMT. Most importantly, patients are encouraged to eat appropriate quantities as well as varieties of food throughout the day. Eating in this way is an emotional exposure; however, it is also necessary for basic physical health. Initially in eating disorder treatment - very much unlike exposure therapy for any other disorder - patients are actually encouraged to distract themselves during meals. This is because the priority is actually consuming appropriate quantities of food (e.g. enough for weight gain in anorexia nervosa) and keeping the food down, rather than exposure to negative emotions. Only after food is eaten are patients asked to check in with their emotional experience, rate their negative emotions (e.g. anxiety, guilt, disgust, shame, etc.), and tolerate them. As treatment progresses, patients are encouraged to distract less during meals and experience their emotions, so long as the meal is completed.

Further, in IMT, therapists are strongly encouraged to guide patients through imaginal exposures involving fear of fatness (e.g. imagining gaining weight) as well as whatever consequences the patients fear will occur because of this weight gain (e.g. being rejected by peers). In this way, not only is avoidance of fear of food being addressed, but core fears of "fatness.”

Can Dietitians Use IMT for Eating Disorders?

Can dietitians benefit from using the IMT Handouts/Worksheets that come with the manual, Treating Eating Disorders in Adolescents? Sure! The Regular and Appetitive Eating (RAE) module is particularly suited for use in dietary/nutrition counseling.

You can download the IMT Handouts/Worksheets that come with the manual from New Harbinger's site at: https://lnkd.in/dXDa3hv.

The following RAE Handouts are particularly useful for dietitian use: 3, 5, 6, 9, 12, 13, 15, 17, 18, and 19.

See attached for sample RAE Handouts for use in dietary/nutrition practice!

IMT for Eating Disorders: Should I Use Regular or Appetitive Eating?

IMT Question: "Should I use regular eating or an intuitive/appetitive approach with my patient?"

IMT Response:

The answer is both! Rather than viewing regular and intuitive/appetitive eating as opposing methods, we have integrated these approaches into a module called Regular and Appetitive Eating (RAE). You can find the guidelines on administering Regular and Appetitive Eating (RAE) in, Treating Eating Disorders in Adolescents, along with a series of free handouts/worksheets for the patient in the accompanying PDFs.

In short, the guidelines in the book recommend that regular eating first be established with the use of food logs etc. Once generally appropriate quantities and varieties of food are being eaten, patients begin to to develop the skills required to detect the appetitive cues of hunger and fullness (e.g. mindfulness). Once these cues can be detected, patients experiment with eating in accordance with the cues.

In Regular and Appetitive Eating (RAE), patients are instructed to eat meals within general windows of time (e.g. 7-8:30am, 12-1:30pm, and 6-7:30pm) as well as in accordance with their appetitive cues of hunger and fullness. Snacks work similarly.

Regular and Appetitive Eating (RAE) is one of six different modules presented in the larger Integrative Modalities Therapy (IMT) for eating disorders, described in the book. RAE is presented as part of individual therapy along with interventions for improving body image. There are also interventions for group and family therapy in the IMT collection.

Below is a photo of one of the RAE Handouts.

If anyone has any questions, please feel free to reach out!

IMT for Eating Disorders: Does Removing Body Checking Triggers Foster Body Avoidance?

As the doctoral students I supervise ask questions about Integrative Modalities Therapy (IMT) for eating disorders, I'll be addressing them in the Community of Professionals for Learning IMT group on Facebook. For a short period, these articles will be posted here as well.

Student Question: "Isn't removing triggers for body investigating/checking (e.g. covering the mirror) fostering body avoidance?"

Response: You can combine the techniques of removing triggers with body exposure exercises. For instance, having a patient cover mirrors at home towards the end of decreasing body investigating, does not mean that an additional body exposure exercises cannot concurrently be added to treatment. It is possible to both conduct in-session in vivo body exposures by looking in the mirror as well as assigning the homework of looking in the mirror for 5 minutes at home once per week.

In IMT terms, this means that you can teach the ROCKS skills for Body Investigating while also conducting in-session in vivo exposures as well as assigning them for homework.

Please feel free to join our private community of IMT professionals on Facebook! Building a sense of community is essential to collectively tackling these illnesses.

An Interview with IMT for Eating Disorders Author, Tara Deliberto PhD

In preparation for pub day on 8/1, I did this interview with my lovely agent, Carrie! Here is the article she posted on her website below.

-Tara Deliberto, PhD

Pub Day Interview!

Tell us a bit about you and what you do.

Sure! I'm a psychologist with a job that looks different than what most people might imagine. I work at NewYork-Presbyterian Hospital with people diagnosed with eating disorders who currently need what is referred to as a "higher level of care" (e.g. inpatient hospitalization). Rather than attending therapy once per week, the patients with whom I work need care every day at a hospital from a specialized multi-disciplinary team to foster both physical and psychological recovery from eating disorders. Several years ago, I opened and directed a "partial hospitalization program" or PHP where adult patients come in for treatment from 8:00am-3:00pm, Monday through Friday. This program offers patients an opportunity to either step down from inpatient care or prevent hospitalization.

Currently, I am an assistant professor at Weill Cornell Medicine, the medical college of Cornell University, working in the program at NewYork-Presbyterian that I created, training advanced doctoral students as well as post-doctoral fellows. In this role, I teach an eating disorders seminar at the hospital that all staff members and students at the hospital are welcome to attend. While carrying out my roles as a hospital psychologist, administrator, and teacher, I worked on creating a new treatment approach called Integrative Modalities Therapy (IMT) for eating disorders along with my colleague, Dina Hirsch, PhD.

How did you put together the research for this book and what made you realize that you should write it?

Ironically, I spent my first four years of training with the thought "I want to treat everything but eating disorders because they’re just too difficult." I know a lot of clinicians think the same. But when I saw the state of things, I felt entirely differently. In fact, the treatment landscape for people with eating disorders – the deadliest of mental illnesses - was so bleak that felt compelled to devote my career to improving the quality of care. I knew that clinicians used to think, “I want to treat everything but borderline personality disorder because it’s just too difficult” until Marsha Linehan, PhD, created Dialectical Behavior Therapy (DBT). Then, clinicians started enthusiastically treating borderline personality disorder because they loved learning DBT. It was clear that someone needed to do the same for eating disorders.

The journey of creating IMT started years ago when Dina Hirsch, PhD, was my supervisor at a partial hospitalization program for adolescents with eating disorders at NorthWell Health. I was fairly new to the treatment of eating disorders at the time and was shocked to find that there was simply no evidence-based treatment material written for use with adolescents with eating disorders. The modus operandi at the time was to use repurposed material for adults with other disorders such as anxiety or borderline personality disorder. I remember saying to Dina: "we have to do better than this!" She agreed. Later that day, we were in a required meeting and I passed her a note with the sketched out plan for IMT I had been mulling over since the prior year. Unlike anyone else I told about this idea in the past, Dina immediately encouraged me to follow through with it.

Right away, we started creating group material rooted in either previously published evidence-based treatment manuals or one-off interventions described in research papers. We also started writing similar material for use with parents/carers in our family meetings as well as with patients in our individual therapy sessions. Over time, the collection of interventions – what we now called Integrative Modalities Therapy (IMT) - amassed into three separate works for use in groups, family sessions, and individual therapy.

Others in the field started to express interest in using our materials. Some clinicians even started translating them into other languages for use with their patients. This type of feedback quickly signaled to us that we had been creating a flexible and scalable treatment for eating disorders in adolescents that others perceived as rather easy to administer in both hospital and outpatient settings. It also became apparent that IMT could be used as a tool to train clinicians in geographical regions where eating disorder specialists were sorely lacking. I then started to think that maybe this could be the treatment that interested clinicians in eating disorders. Understanding the potential for IMT to help, we set out on a mission to see it published and disseminated, hoping to contribute to the efforts made by those in our field to improve care.

What makes the type of treatment outlined in your book different from what is already out there?

IMT is rather different than what is out there for several reasons, some of which are likely surprising. As mentioned above, IMT is chiefly different than what exists in that it includes handouts/worksheets steeped in evidence-based treatments for adolescents. To our knowledge, nothing like this existed before IMT. It is also different from any other type of manualized treatment we know of in that there are interventions designed for three separate types of therapy settings: individual, group, and family therapy. Lastly, unlike other treatment protocols, IMT is designed to be used very flexibly. Each handout contains an intervention for a specific issue a patient may or may not face. As such, each patient gets a different set of treatment materials depending on what they need.

Relatedly, IMT is different in that the material can be used flexibly in inpatient settings.

Yes! Absolutely. Specifically, IMT is rather different in that it was created for use in inpatient, residential, and day treatment settings, as well as in outpatient settings. Most treatment manuals seem to be written specifically for use in outpatient settings. Due to factors such as the medical precariousness of our patients, however, many people with eating disorders are treated at higher levels of care (e.g. hospitals, residential programs, etc.). Considering that 1) other manuals are written for use in outpatient, and 2) a large and important portion of eating disorder treatment is delivered at higher levels of care, there was a big disconnect between what was available and what is needed. For instance, when an adolescent with anorexia nervosa is healthy enough to be in outpatient care, family therapy is absolutely essential. The outpatient manual, therefore, prioritizes interventions with the parents/carers. At higher levels of care, however, the patient is attending treatment groups all day with peers. Patients, therefore, need standardized evidence-based materials to be administered during those times.

Are eating disorders diseases that easily are ignored or dismissed by their sufferers or their families?

Both people with eating disorders and their families are often completely unaware of the illness. Eating disorders are different than most other types of mental illnesses in that they are considered to be “egosyntonic.”  Generally, this means that a patient does not present as wanting to recover from the illness. Food restriction, for instance, may be viewed by patients and//or their families as “healthy,” rather than as part of a life-threatening mental illness. As such, people with eating disorders may present as being unmotivated or unwilling to change behaviors they perceive as healthy. Similarly, family members may also present as unwilling to aid a person with an eating disorder in recovery if the perils are not fully understood.

Other patients and family members, however, do recognize eating disorder behaviors as problematic, but do not feel equipped to address it for variety of reasons. For instance, when confronted about the illness (e.g. a family member prompts more food to be eaten at a meal), a person with an eating disorder may have an explosive reaction, resulting in the family member drawing the conclusion that “it is not helpful to interfere.” In IMT, a behavior that is aimed at / results in others withdrawing support (e.g. having an explosive reaction), is referred to as an “eating disorder protective behavior (EDPBs).” Despite knowing that a problem exists, family members can become conditioned to ignore the eating disorder when people engage in EDPBs. Without having the skills to address the problem nor knowledge of how to access resources, many family members simply abandon efforts to intervene, feeling helpless.

Especially considering the variety of factors preventing people with eating disorders and their families from recognizing and/or addressing the illness, it is up to clinicians to know that eating disorders are life-threatening illnesses that require immediate psychological, psychiatric, and medical treatment. Of note, eating disorders are much more common than even ten years ago. In fact, a recent study showed that the number of eating disorders cases has doubled in recent years (Galmiche, et al., 2019). Research is also is showing that people of all genders, ethnic backgrounds, ages, and socio-economic statuses have eating disorders. In short, because eating disorders are 1) ego-syntonic, 2) life-threatening, 3) have a rapidly increasing incidence, and 4) impact people from all backgrounds, we strongly recommend that all people presenting for therapy should be screened for eating disorders.

Can you tell us a bit about IMT and its mission?

With IMT - a curated collection of evidence-based interventions – we aim to help patients develop skills, support families, and provide a way for clinicians in the trenches to communicate core treatment concepts. We also hope to attract new clinicians willing to treat eating disorders, so that more treatment options are available to patients. In short, our mission is to help close the treatment gap.

Integrative Modalities Therapy for Eating Disorders

Back in March of this year, the approach that Dina Hirsch, PhD, and I created for the treatment of eating disorders was renamed Integrative Modalities Therapy (IMT)!  Here I'll explain the reason for the change as well as the meaning of the new name.

When we started out, our aim was to create a comprehensive collection of evidence-based interventions for patients and families with eating disorders.  For the original plan, we knew that we needed to have an approachable patient-and-family-facing name.  We decided to call the first version of our book "BITE," or Behavioral Interventions, Tips, and Evaluations.  At the time, this name was fitting since the acronym represented the smallest behavioral step a person can take towards recovery (i.e. taking a bite of food) and the fully spelled-out name descriptively explained what was included in the book. It was a go!

Over the years, however, our singular book that brought together interventions, tips, and assessments grew into something much larger: an evidence-based practice treatment approach.  We soon needed to write a treatment manual for clinicians to use alongside the original book for patients and families. Our unpublished manuscript became a resource for clinicians in the trenches who needed a summary of all of the varied evidence-based interventions in one easy place.  Some have called our approach "evidence-based practice in a box."  Recognizing the potential of this type of resource, our goal became to provide clinicians with a comprehensive, practical, flexible, and scalable resource to help navigate the treatment of eating disorders. 

Considering these advancements, prior to both books being published by New Harbinger, it was time for a new clinician-facing name!  We chose to rename our approach Integrative Modalities Therapy (IMT) because it integrates a wide array of evidence-based interventions from gold-standard treatments into the three modalities of individual, group, and family therapy.  In short, the approach is both integrative and can be administered modularly across the three treatment modalities.  As a clinician-facing evidence-based practice approach, we now have the big, hairy, audacious goal of contributing to the efforts of our colleagues by helping to close the eating disorder treatment gap together.

What is Purging Disorder and How is it Treated?

by Tara Deliberto

Purging disorder is characterized by the presence of purging behaviors (e.g. vomiting, laxative use, etc.) aimed at influencing body size/shape/weight in the absence of binge eating and purging cycles. In other words, the purging exists separate from binge eating. Technically, purging disorder falls under the "Other Specified Feeding and Eating Disorder” - or OSFED - category in the DSM-5.

Relatedly, no treatments currently exist specifically for the treatment of purging disorder in adolescents, to our knowledge. After we received inquiries about whether or not Integrative Modalities Therapy (IMT) can specifically address this disorder, we were inspired to write about it!

Yes, IMT can absolutely be used to treat purging disorder. In fact, IMT was designed to treat all eating disorders. Further, it is intended to be used flexibly. As such, not every handout is going to be useful to administer to every patient. Patients with purging disorder are no exception!

Although every IMT handout may not be useful in treating purging disorder, many will be. This is up to the therapist to determine. That said, the IMT handouts listed below would be particularly helpful in treating the majority of those with purging disorder.

If you are interested in learning more, please feel free to contact us directly or join one of the online IMT communities such as our private Learning IMT Facebook Group!

IMT Handouts for Use with People who have Purging Disorder

Individual Therapy

Regular and Appetitive Eating (RAE) Handouts 1, 3, 4, 8, 14

Body Acceptance and Exposure (BAE) Handouts 6, 7, 15, 16, 18, 19, 21

Group Therapy 

Mindfulness and Acceptance (MAC) Group Handouts 1, 2, 3, 6, 19 (the NO PURGE Skills) 

Cognitive Behavioral Therapy (CBT) CBT Group Handout 12

Family Therapy

Stage 1 Family Handouts 1.4, 1.5, 1.6, 1.7, 1.9, 1.12, 1.15, 1.17, 1.18, 1.29

Stage 2 Family Handouts 2.2, 2.6

Why We Created IMT for Eating Disorders

by Tara Deliberto, PhD

The journey of creating IMT started years ago when Dina Hirsch, PhD, was my supervisor as I trained in a hospital program for adolescents with eating disorders.  I was fairly new to the treatment of eating disorders at the time and was shocked to find that there were simply no evidence-based treatment material written for use with adolescents with eating disorders in groups.  The modus operandi  back then was to use repurposed material for adults with other disorders such as anxiety or borderline personality disorder.  I remember saying: "we have to do better than this!"  Dina agreed.  Out of necessity, we started creating group material together rooted in either previously published evidence-based treatment manuals or one-off interventions described in research papers.  We also started writing similar material for use with parents/carers in our family meetings as well as with patients in our individual therapy sessions.  Over time, the collection of interventions amassed into three separate books of handouts/worksheets for use in groups, family sessions, and individual therapy.

Soon others in the field started to express interest in using our materials.  Some clinicians even started translating them into other languages for use with their patients.  This type of feedback quickly signaled to us that we had been creating a practical and scalable treatment for eating disorders in adolescents that others seemed to perceive as practical and easy-to-administer in both hospital as well as outpatient settings.  It also became apparent that IMT could be used as a tool to train clinicians in geographical regions where eating disorder specialists were sorely lacking.  Understanding the potential for IMT to help treat eating disorders we set out on a mission to see IMT published and disseminated, hoping to contribute to the efforts made by those in our field to improve care. Eating disorders are deadly illnesses. They are also different than many other disorders in that they are self-eclipsing (i.e. people may not be aware that they have an eating disorder, nor may they state they want to recover.) Being specialists in how to treat these illnesses, we want to do anything we can to spread knowledge to clinicians, families, and patients about how to best treat them.

If you’re interested in pre-ordering the IMT clinician’s manual published by New Harbinger, visit Amazon here!

And always feel free to message us with any questions!

All the best,
Tara

IMT Resources will be Available through Amazon and the New Harbinger Website

Hi there! If you happened to have pre-ordered an IMT Client Resource Book from Amazon, you will likely be receiving a notification regarding reimbursement. New Harbinger is restructuring the way the books will be sold. The IMT Clinician's Manual *will* be printed and for sale on Amazon through New Harbinger. Conversely, the Client Resources will be sold in PDF format for a nominal price to clinicians via the New Harbinger website starting on 8/1! Thank you so much for your continued support. We're very excited for the IMT material to be publicly available in less than two months!

Evidence-Based Practice for Eating Disorders and IMT

We are weeks away from the IMT books being formally published by New Harbinger on 8/1! In preparation, we thought it would be helpful to describe the unique "evidence-based practice" approach that IMT takes.

So, what is an evidence-based practice (EBP) approach? According to Sackett et al. (2000), EBP is the mindful use of the currently available evidence to inform decisions about the implementation of treatment for an individual patient. It includes the following three components:

1) a thorough search of and critical review of the available evidence,

2) a clinician's own experience and expertise, and

3) the preferences of the individual.

The IMT books formalize the EBP process into a written format, with the goal of informing clinicians about how eating disorder specialists may treat various presenting problems. These books are a collection of evidence-based interventions compiled into individual, group, and family therapy modalities, that were - until now - scattered across academic journals and only used by practitioners in-the-know. In short, IMT aims to inform clinicians who do not have such highly specialized training/experience about what the pros actually do in the trenches. Considering the serious lack of training clinicians across all mental health disciplines receive on the treatment of eating disorders, the deadliest of all mental illnesses, it seems to us that this type of practical and informative EBP approach is sorely needed.

Being that IMT takes an EBP approach, the manual is not a rigid protocol that has been investigated by many independent researchers; instead, it is a reflection of what clinicians trained in evidence-based approaches might do in practice, given specific circumstances and patient needs not accounted for by existing protocols. This kind of approach inherently provides the clinician with flexibility and autonomy regarding which interventions to implement, depending on the needs/preferences of the individual patient. As such, there is both a standardized set of interventions in IMT as well as the ability to individualize care for the patient by administering them selectively. In addition to its standardization, flexibility, and ability to be used in an individualized manner, we hope that IMT will be scalable, meaning that it can be easily learned and implemented in practice.

Borrowing a business term, our big hairy audacious goal (B-HAG; yes, that's an actual term) was to create a standardized, flexible, able-to-be-individualized, and scalable treatment with IMT to help with filling in a deadly treatment gap. Considering the step-by-step format of the manual, it has been described as "evidence-based treatment in a box." We aimed to write a manual that benefits both trainees and clinicians in more remote areas of the country/English-speaking world as well as patients and their families.

For updates on the IMT project, sign up at: http://bit.ly/2MiijBQ.

The Importance of Accepting Recovery

Imagine the following: no matter what you do to try to change your body size, shape, and weight - whether it be diet, exercise, or liposuction - it instantly returns to exactly the way it is now.

What thoughts and emotions does that scenario bring up for you?

For some people, this exercise immediately prompts feelings of anxiety and loss of control. Some can be so provoked, they immediately shut down the experience by logically poking holes in the scenario such as “this couldn’t be real, so I don’t feel anything because I know I can control my body.” For others, relief from the constant struggle with their body will be felt. After all, if nothing can be done to change something, you might as well start accepting it, right? Only those who truly accept their body will be left unmoved by the exercise.

Beyond an interesting thought experiment, this exercise is an important Integrated Modular Therapy (IMT) tool on the road to recovery. This post explores some reasons why.

In eating disorders, recovery itself is feared and avoided. People with eating disorders have a fear of fatness and recovery is equated with fatness. As such, recovery is feared and behaviorally avoided through the engagement of eating disordered behaviors (e.g. calorie restriction, food avoidance, binge eating, intolerance behaviors such as purging, etc.). Because recovery is feared and avoided, imagining what it would *really* mean to be recovered is an interesting avenue for treatment.

In essence, the recovery entails: 1) refraining from engaging in attempts to change the bod, therefore, 2) experiencing a variety of negative emotions and other internal experiences (e.g. physically feeling full), and ultimately 3) coming to accept one’s body in the absence of attempting to change it. As such, exercises like the one above are designed to engender these experiences.

Because people with eating disorders can be unwilling to totally abandon eating disorder behaviors (i.e. attempts at changing their body), positing a world in which they cannot change their body prompts acceptance through the experience of learning to tolerate negative experiences crucial to recovery (e.g. loss of control and refraining from behaviors) that would otherwise be avoided. As such, this exercise primary serves as an imaginal exposure exercise.

In addition to prompting patients to learn to cope with negative emotions about recovery, this exercise often engenders positive emotions. For some patients, the participation in this exercise is the first time they really experience any sort of relief regarding the absence of eating disorder behaviors. Experientially knowing that abandoning the eating disorder behaviors can be a relief is very salient for some.

In summary, from an Integrative Modalities Therapy (IMT) perspective, the healthy alternative to trying to change the body is active acceptance. Acceptance can be fostered by identifying what is being avoided (e.g. particular aspects of recovery), then engaging in a crafted exposure to those negative stimuli.

Conducting Mindfulness Exercises in Eating Disorder Treatment

by Tara Deliberto, Ph.D.

If you have never conducted a mindfulness exercise before, it can be difficult to know where to start. This post is intended to walk you through the various steps involved in conducting a mindfulness exercise in session.

First, prior to conducting an exercise, it is helpful to try some out on your own. Perhaps try downloading a mindfulness app for assistance. I recommend doing one 3-5 minute exercise per day for a couple of weeks. Be sure to check in with yourself after the exercise and note your internal experiences. What are you thinking? How does your body feel? What emotions are you experiencing?

Next, you’re going to need a Tibetan singing bowl. A small one is fine. They can easily be purchased online or in spiritual shops. Once you have your bowl in hand, practice ringing it. If the mallet has a felt tip, hold the mallet by the wooden portion. Practice lightly hitting the felt side of the mallet on the side of the bowl.

Once you’ve practiced mindfulness and using the singing bowl, it is time to start rehearsing conducting an exercise. Select a mindfulness exercise (e.g. leaves on a stream) that is about 3-5 minutes in length for clinical settings. Then follow these steps:

1. Ring the Tibetan singing bowl three times to start.

2. Wait for the third bell to stop ringing then begin.

3. No matter what type of mindfulness exercise you're doing, it can be helpful to start with something grounding such as saying "Notice your back against the chair and your feet firmly planted on the ground.  Take a moment to anchor yourself here."

4. Then it can be helpful to focus on the breath for a few moments before getting into a non-breath focused exercise. You might say something like “Bring your attention to your breath. Notice your inhales and exhales. Do not force your breath, but instead allow your breath to breathe you.”

5. Explain the exercise (e.g. leaves on a stream). For instance, “You are sitting at the bank of a river under a leafy tree. Notice what it feels like to sit on the ground. Is it soft or hard? Now notice the river. Which direction is it flowing? How fast is the water moving? Bring your attention to the sun over head. How brightly is it shining? Continue to imagine yourself at the bank of this river. Whenever your mind gets distracted, put your thought on a leaf from the nearby tree and let it float down the river. Each time your mind wanders, simply reimagine yourself on the bank of a river, put your thought on a leaf, and watch it float away.”

6. Every 10-30 seconds prompt a refocus. For example, "If your mind has wandered, that's ok because that's what minds do. Simply acknowledge that it has done so and willingly bring your attention back to the exercise (e.g. sitting on the bank of a river).

7. Signal the end of the exercise by saying something like "Now, before we end, bring your attention back to your breath."

8. Signal that attention should be brought back into the room "Start to notice yourself sitting in your chair."

9. Prior to ending, tell everyone "Now I'm going to ring the bell twice, and after the second bell stops ringing, you can go ahead an open your eyes."

10. Give everyone a moment to settle in.

11. Ask for observations.

12. Be sure to verbally and non-verbally (smile) reinforce efforts to refocus attention, willingness to participate, and improvements since starting mindfulness practice. For instance, in response to someone saying “my mind wandered, but I was able to refocus back on the exercise,” you might say “really nice job catching your thoughts and willingly refocusing on the exercise.”

And that’s all there is to it!

Conducting mindfulness exercises can be challenging, but with practice it can be rewarding.

I very much hope this was helpful! Please feel free to leave comments.

Announcement: Intensive Program for Adults with Eating Disorders Now Opened in the NY-Metro Area!

by Tara Deliberto, Ph.D.

I'm very excited to announce the opening of a new intensive program from adults with eating disorders at NewYork-Presbyterian Hospital!  This program runs from 8:30am-3:00pm, Monday-Friday, and provides adults with eating disorders the opportunity to eat three times per day with the support of caring and well-trained behavioral specialists.  In addition to meal and snack support, patients receive individualized care while having access to a host of groups focusing on goals such as establishing understanding and use of cognitive behavioral therapy skills, mindfulness practice, assertiveness, and the regulation of one’s emotions.   Taken together, the services offered to our patients - including meal and snack support, individual therapy, family therapy, and group sessions - foster both mental and physical recovery from disabling and life-threatening eating disorders.   

Although our eating disorders partial hospitalization program (ED PHP) is new, New York-Presbyterian Hospital has served the community by treating patients in both inpatient and outpatient settings for many years. Our specialized eating disorders inpatient unit helps people psychologically recover from eating disorders, while benefiting from close medical monitoring of physical symptoms resulting from food restriction & avoidance, purging, laxative use, and other eating disordered behaviors.  Additionally, we have outpatient services where people with eating disorders can see licensed mental healthy professionals for 1-2 sessions per week.  Until now, however, patients with any form of insurance in the NY-Metro Area have not been afforded the opportunity to have an intermediate level of care in a hospital setting in which support, psychological services, & medical monitoring are provided consistently throughout the week.

In this new eating disorders partial hospitalization program (ED PHP), patients are treated & supported by staff from the disciplines of nursing, social work, psychology, nutrition, & psychiatry, who work together to help people recover both mentally & physically from the effects of the eating disorder.  Leadership of this new program will include myself, Tara Deliberto, Ph.D., Assistant Professor of Clinical Psychology in Psychiatry at Weill Cornell Medicine, and Director of the Eating Disorders Center’s Partial Hospitalization Program at New York-Presbyterian Hospital, as well as Evelyn Attia, MD, Professor of Psychiatry at Columbia University Medical Center, Professor of Psychiatry at Weill Cornell Medical College, Director of the Eating Disorders Research Program at the New York State Psychiatric Institute, and Director of the Columbia Center for Eating Disorders at Columbia University Medical Center.   

For more general information about the Eating Disorders Center: http://www.nyp.org/psychiatry/services/center-for-eating-disorders.  More info on the ED PHP will be up soon!