Panel Discussion with Clinicians from Mirasol Eating Disorder Recovery Centers
Vegetarian, vegan, low-carb, raw, paleo — all claim to be the “ideal” diet, and adherents preach the benefits with the conviction of religious converts. But the current obsession with “clean” or “healthy” eating can have very unhealthy consequences. Mirasol clinicians gathered to talk about the roots of orthorexia, how it differs from anorexia, and the red flags that help health professionals and family members distinguish between selective or “picky eating” and an eating disorder.
Clinical Director, Adult Program
Ann Twilley, MA,
Massage and Exercise Therapist
Download Audio: M4A
Diane Ryan: “Orthorexia is not exactly the same as anorexia. The strict translation is ‘righteous eating’. So it has a few different components than anorexia although some of the components are the same. The thing that characterizes orthorexia, in addition to the restrictiveness that’s created by the narrowing down of food choices, is the fact that there’s this ‘virtuous’ component to it. It often comes from peoples’ desires to eat healthy, and it just gets out of hand and becomes extreme. And I think the general consensus is that ‘it becomes a problem when it becomes a problem,’ when your decision to eat healthy prevents you from interacting socially, when it prevents you from normal relationships or normal ways of eating or normal places to go and ways of participating. And it also seems to impact the person’s self-perception, so you can’t feel really good about yourself unless you eat in a certain way that’s very very clean and pure, and foods have to come from certain sources. There’s always a component of, ‘my self-esteem comes from the fact that I eat a certain way, and therefore if I don’t, I have a lot of harsh self-judgment.'”
Anne Ganje: “Orthorexics won’t often say ‘I want to lose weight.’ It can start with these diets that become very popular, and all of these books that promote health and cleansing and purity are very attractive, but once orthorexics or anorexics start diving into this, they realize that the consequences are weight loss. Then they get affirmed by their peers and culture, and that can be very addicting. There’s also a high from fasting in and of itself. So the desire to cleanse or to be pure will promote a physiological response of feeling high, and then the culture and peers really promote that. It’s often correlated with trauma, so that cleansing is a symbol of ‘I’m cleansing my body from what I feel shame about.'”
Moderator: “When somebody comes into treatment with a long list of food preferences or food allergies, how can you identify which ones are legitimate?”
I think the general consensus is that ‘it becomes a problem when it becomes a problem,’ when your decision to eat healthy prevents you from interacting socially, when it prevents you from normal relationships or normal ways of eating or normal places to go and ways of participating.
Anne Ganje: “It’s something that we have to deal with every day, and I think the level of attachment and what it brings up for the client when they’re given guidelines, and told what we do and don’t allow. We do allow three dislikes and we certainly honor legitimate allergies and intolerances. But when there’s a lot of fear and anxiety, and behaviors escalate, that’s always a sign for me as a dietitian that’s there something much more than nutrition going on, that there are layers of trauma and anxiety that they’re trying to cover up through the use of food. An orthorexic might start by becoming a vegan or a raw foodist, but it becomes more rigid and stricter, and then malnutrition starts to set in.”
Diane Ryan: “And when you have malnutrition, you’re going to have fairly quickly symptoms of cognitive failure of one sort or another, so the person’s ability to make good choices is decreased.”
Moderator: “It must be very difficult to persuade them that something they have been conditioned to believe is healthy eating is now a health problem for them. How do you go about disabusing them of that notion that what they’re doing is healthy and ‘cool’?”
Anne Ganje: “I think it’s spending part of my time as a dietitian engaging in conversation with the clients about faulty belief systems around healthy eating and what it means to be a healthy individual, and then also working with the shame and the fear that come up around food.”
Maeve Shaughnessy: “When somebody goes to their doctor and says, ‘This is what I’m eating and I seem to be underweight,’ if they’re working with a doctor who doesn’t have any sort of eating disorder specialty, it’s going to be … applauded!”
Moderator: “Are there things that you would want school counselors, and doctors to know to look for to help them identify when picky eating is actually becoming problematic?”
Kira Vredenburg: “I would look at the importance of balance, keeping an eye on whether that person is cutting out whole food groups, and then seeing if that’s affecting the individual’s life. Is making those food choices taking away from their lives? Is it making it hard for them to go out with friends? Is it making it hard for them to do well in school?”
Anne Ganje: “I think there’s a real difference between picky eating and orthorexia. Children, in the absence of any kind of trauma or serious dysfunction, typically would not have the ability to understand or indulge in orthorexic behaviors. But when it becomes something that is cutting you out of life and social activities and connection with others — when it becomes a way to spirituality and peace and decreased anxiety — that addictive use is when it becomes a problem.”
Maeve Shaughnessy: “One other component of orthorexia that I don’t think we’ve highlighted quite enough is the exercise component. That’s another red flag to look for, that quest to optimize a healthy lifestyle, when an individual focuses in on exercise, and ‘How do I perform the best, and feed my body the best so that I can perform the best?’ I think that’s really common in athletes, and we have quite a few athletes that come [to Mirasol]. You asked the question earlier, ‘How do we tease apart this healthy mindset versus an eating disorder when it’s so ingrained into their identities,’ and that can be a really challenging thing to pick apart.”
It’s very similar to PTSD or trauma, where we talk about their lives slowly becoming more narrowly focused. It’s very gradual, so by the time they get there they don’t realize how much they’ve given up and how much they’ve changed.
Katie Klein: “I was doing a little googling prior to the discussion, and the word that kept coming up was ‘obsession’: an obsession with eating healthy, an obsession with purity.”
Ann Twilley: “When it interferes with peoples’ lives, and they can’t do the things they want to do, that’s how I approach it. ‘Okay, you say you want this lifestyle, you say this is really important to you, and yet it has limited what you can do in your life. It’s limiting you from engaging socially or with family members.’ And that’s the biggest thing I see. We had a client who ate only raw food, and she couldn’t go to any family functions, she bowed out of pretty much anything involving food, and that’s just about everything socially. So I think that’s a huge piece of it, the obsession piece for sure, and also how it limits their lives.”
Jamelynn Evans: “It’s not only the limitations on freedom, but also the limitations on how much of their day — and their life — becomes about buying the food, planning the food, going to the farmers’ market, making the food …. So, not only they are missing out engagements with people who are eating other things, but also how free are they to live a life that revolves around anything but food?”
Ann Twilley: “It’s very similar to PTSD or trauma, where we talk about their lives slowly becoming more narrowly focused. It’s very gradual, so by the time they get there they don’t realize how much they’ve given up and how much they’ve changed.”
The annual Wilderness Therapy Symposium is a great opportunity to meet and share best practices with clinicians, instructors, researchers and guides from wilderness programs all over the world. For me, one of the highlights of this year’s symposium was a pre-conference workshop on current research on outdoor behavioral healthcare. Findings related to the impact of treatment interventions underscored the significance of non-structured time spent with clients. This was followed by a workshop addressing the latest findings in the field of neuroplasticity and the implications for behavioral health.
Until recently, it was thought that the brain stopped developing after the first few years of life, and that if part of the adult brain was damaged, the nerve cells could not regenerate or form new connections. However, ongoing studies are demonstrating that the brain continues to reorganize itself by forming new neural connections throughout life in response to changes in our feelings, thoughts, experiences and the way we use our bodies. As we engage in habitual behaviors, such as eating disorders or substance abuse, neural pathways become entrenched, increasing the likelihood that the behavior will be repeated. But the plasticity of the brain means we can retrain the brain to develop new neural pathways that support recovery.
Research on the mechanism of neurological change indicates that several driving forces need to be present for neurogenesis to occur:
- Exercise – One of the key locations in the brain for the production of new neurons is the hippocampus. Studies show that this area of the brain contributes to memory formation and organization. Exercise can increase blood flow to the hippocampus and improve the acquisition of new learning as well as memory. A study by Henriette van Pragg installed running wheels in rat cages. She found that wheel running produced both increases in hippocampal volume and improvements in memory and maze running. Interestingly, forcing the rats to exercise, rather than allowing them to exercise, negated the neurogenic effects, as did stress. Running appears to create optimal conditions for new neuronal development, however as little as three hours a week of brisk walking has been shown to halt or even reverse the brain atrophy that begins in middle age. Through increased blood flow to the brain, exercise triggers biochemical changes that help generate new neurons and new inter-synaptic connections.
- Mindfulness – Meditation in various forms and other mindfulness practices, including mindful eating, provides a context for change to occur. Awareness of the workings of the nervous system and how it impacts behavior is the first step toward choosing to change, letting go of limiting beliefs and creating a recovery mindset.
- Novelty – Our brains are hard-wired to appreciate and seek out novelty. Animal studies have shown that exposure to a novel environment or stimuli increases the brain’s ability to create new connections between neurons by activating the midbrain area, increasing dopamine levels, and motivating us to explore our environment in search of potential rewards.
Neuroplasticity is revolutionizing the field of behavioral health and underscoring the critical role of experiential therapies. Mirasol is proud to offer eating disorder treatment programs that maximize the conditions for new neural patterning, including EMDR, yoga, TRE, art therapy, polarity therapy, somatic therapy and dance-movement therapy. Our adventure therapy and wilderness programming add an element of novelty, encouraging clients to expand and discover innovative solutions to challenges and uncover hidden strengths. As clients participate in service projects that expose them to new groups of people and circumstances, they become more skillful at reframing their perceptions of themselves, creating their own pathways to lasting recovery.
If you’ve ever considered residential eating disorder treatment, your dietitian or therapist may have recommended something called “PHP” or “partial hospitalization”.
Mirasol, like many other treatment centers, offers a “partial hospitalization” program, but the name is misleading, and there are a lot of misconceptions about the nature and purpose of the program.
For starters, “partial hospitalization” doesn’t mean you’ll spend part of the time in a hospital. On the contrary, you’ll be living at home or in a comfortable residence with other Mirasol clients!
A few photos of Mirasol’s new PHP residence
PHP is often described as a “day” program, but most PHPs actually offer both day and evening programming. It’s just that there are fewer hours of individual and group therapy, and more free time to study, work, volunteer in the community, or attend off-site meetings.
In PHP, the focus of therapy shifts from analysis and discovery to development of practical skills that will help you live in the world after treatment without an eating disorder. PHP is often recommended for clients as a step-down from full-time residential treatment, or to provide additional support for clients already in recovery.
“It’s the bridge between living in a safe environment and doing the deep core work required at the residential level, and then being able to step aside and apply what you’ve learned so that you can live your life in recovery,” says Mirasol Primary Therapist Katie Klein.
Small is Beautiful (and Baffling)
Mirasol’s PHP is very small — never more than six clients in any residence — so treatment plans are highly individualized and adjusted on an almost daily basis to balance the need for support and independence.
“No one’s program here looks the same,” says Klein. “Some clients need more individual sessions with their primary therapist, while for others we may supplement those sessions with Reiki, polarity therapy, neurofeedback, EMDR or TRE.”
There’s an average of two process groups a day, with a strong focus on tool and skill development and coping skills through cognitive behavioral therapy, belief work, mindfulness and meditation as well as dialectical behavior therapy, supported by weekly psychodrama, art therapy, poetry and spirituality groups.
Compulsive Exercise: Eating Disorder’s Evil Twin
Many clients have an unhealthy relationship with exercise as well as an unhealthy relationship with food. For example, 90% of bulimics exercise to compensate for episodes of binge eating.
“Developing a healthy relationship with exercise is a very important part of the PHP program,” says Program Director Nikole Corcoran. “With staff support, clients learn to exercise appropriately, to cope with the feelings that come up when they can’t exercise, and to make sure that they’re exercising for the right reasons.”
Tara Shultis, Massage and Movement Therapist, develops individualized exercise plans for each client, and that means working very closely with our naturopathic physician and dietitians.
“Most clients will attend two yoga classes per week, along with rocks and ropes sessions, trips to the gym and low-flying single-point trapeze. We also offer — weather permitting — bimonthly hiking, caving or backpacking trips.”
Keeping It Real in the Kitchen
Of course one of the biggest challenges of transitioning to life after residential treatment is making sure each client has the tools she needs to plan and prepare healthy meals. Corcoran was surprised to discover that some PHP programs don’t focus on teaching clients how to properly feed themselves.
“All the food is prepared for them, and sometimes they don’t even serve themselves, so they leave treatment knowing what their meal plan is, but with no idea how to implement it. So we put a lot of emphasis not only on food preparation and cooking, but also on breaking down labels and really understanding what those labels mean.”
Dietitian Anthony Hackworth meets with clients every Monday to work out a menu plan for the week. He also accompanies the clients on weekly grocery shopping outings to reinforce their healthy food choices and provide assistance with label-reading.
At weekly cooking classes, Mirasol chef Deirdre O’Leary teaches basic cooking skills, including tips on prep work, knife skills, and healthy fats. Deirdre is not only a fantastic chef, but a wonderful entertainer, seasoning her sound advice with entertaining tips for “getting down with your food”, letting vegetables “party in the pan” and judicious use of “aerial assault”. There’s a video of Chef Dee in action on our web site.
“Opportunities to Be Uncomfortable”
The individualization and fluidity of the program are its greatest strengths, but may also be a source of frustration for some clients.
“One of the things PHP can and must provide is the opportunity to be uncomfortable”, quips Mirasol’s Executive Director Diane Ryan. “That period of transition from the protective cocoon-like environment of residential treatment to life on the outside is the messiest, scariest phase in the recovery process.”
In residential treatment, the daily schedule is filled with individual and group therapy sessions, scheduled meals and snacks and recreational activities. Clients are supervised 24/7 to reduce eating disorder cues and triggers, and access to other medicators is severely restricted. In PHP, on the other hand, the daily schedule is deliberately salted with unstructured time and opportunities for clients to make their own choices, including how they’ll cope effectively with periods of boredom, indecision, frustration and anxiety.
The ultimate goal is to provide you with opportunities to practice the skills and tools you learned in treatment, with the support of clinical staff and your peers, in an environment as close to real life as possible. There’s a sample program schedule on Mirasol’s web site at PHP Day Program Schedule.
If you’d like to learn more about Mirasol’s PHP program, speak with one of our counselors by calling 888-520-1700 or visit mirasol.net.
It’s an all-too-familiar story: a brilliant young dancer upstaged by an eating disorder. When Ayla’s illness forced her to drop out of ballet school, she fell into a depression, and her therapist recommended residential treatment.
“I locked myself in my room and I was crying hysterically for like four hours,” Ayla recalls. She credits Jodi Tudisco, Clinical Director of Mirasol Adolescent Program, with saving her life.
“My mom knocked on the door and she handed me the phone and it was Jodi, and Jodi pretty much talked me down from killing myself.”
Ayla reluctantly agreed to treatment, but says she was “a shell” when she arrived.
“My world was so small, and I didn’t really think that anything was wrong with me because I had been sick for so long. I never said ‘no I don’t want to get better’ but it was like ‘I don’t need to get better.’ In the beginning, I found ways to try to manipulate the system because I hadn’t heard a voice in my head that wasn’t the eating disorder for about three years. I didn’t trust anybody, and I always pretended like everything was okay.”
But a month into treatment things began to change.
“Things started coming up, and layers of the onion began to peel away,” she recalls. A visit from her mother reminded her of everything she was missing by being in treatment.
“It was like, ‘what am I doing? I had so many opportunities this summer!’ I was supposed to go to Boston Ballet on a full scholarship. It just hit me that there are better things in life than being in treatment!”
I believe you really have to have a moment where you decide ‘I’m going to let go, I’m just going to see what happens.’ It’s really hard to get up to the top of the mountain, but you can decide if you like the view or not, and you can always run back down the mountain. I really like the view from up here.
And so Ayla began building relationships with other people. She developed a close friendship with another MIrasol client, and they promised each other that they would recover together. She also began creating relationships with members of the staff.
“They’re so open!” says Ayla. “All they want is for you to get better, and you can see it in their eyes, you can feel it when you walk through the door. This place for me has been like a family and a home. Being here has helped me learn that family comes in all shapes and sizes, and that people really really love me.”
Ayla believes a key to her recovery was learning to trust the process.
“Sometimes people just go through the motions until they get to a certain point and they say that they’re better. But I believe you really have to have a moment where you decide ‘I’m going to let go, I’m just going to see what happens.’ It’s really hard to get up to the top of the mountain, but you can decide if you like the view or not, and you can always run back down the mountain. I really like the view from up here.”
Ayla also appreciated the individualization of her treatment at Mirasol. In her case, it was recognizing her love of ballet. She worked closely with her primary therapist and her dietitian to resume dancing on a limited basis at a local ballet school, with corresponding adjustments to her meal plan.
“I thought I would never get back to ballet again, but we took it very slowly. I started out dancing once a week, and began taking a ballet class with other people. And then I did a long day like I would have done at my ballet school. It was just amazing for me to see, I felt so safe and so supported. I have fought my eating disorder so hard to get back to ballet. It’s hard because the profession is a lot about your body. I’m very grateful that I can do what I can do in ballet. And I know it’s not all about your body, it’s about the way you dance, and about how much passion you have inside your soul, and I have a lot of it.”
For the traditional closing ceremony on her last day in treatment, Ayla chose to conclude with the Second Solo Variation from “Emeralds”, the first act of “Jewels”, created for the New York City Ballet by George Balanchine. What a wonderful way to celebrate a dancer’s recovery!
On her last day in treatment at Mirasol’s teen residence, Tori reflects on her experience at Mirasol, including a brief stay at another eating disorder treatment facility.
“Right when I came in, I was cared for and I was loved, and people really wanted
to help me.”
“No other treatment center is like this. It’s so individualized.”
“The therapists here and all of the staff members are very, very caring. You can tell that they really love you and they really want the best for you. I remember going into my sessions and I just felt like I could be myself, like I could say whatever I wanted, whatever I was feeling, and I was not judged at all.”
“I feel like I’m a very strong person because I’m in recovery now, and I wouldn’t have been in recovery if it wasn’t for coming here and learning all these amazing things.”
“I’m looking forward to seeing my family and showing them how amazing I’m doing. I want to prove to them that I’m a much stronger person now and I’m going to kick butt in my recovery.”
Top 10 Eating Disorder Blogs of 2015
Eating Disorder Hope Award
- Orthorexia: The Dirty Downside of “Clean” Eating September 23, 2015
- Changing the Brain: Neuroplasticity and Eating Disorder Recovery September 15, 2015
- Partial Hospitalization (PHP): Myths, Misconceptions and the Mirasol Alternative September 11, 2015
- Ayla’s Finale September 8, 2015
- Tori’s Story August 18, 2015
- Elder Eating Disorders: Is Recovery Possible? August 10, 2015
- Mirasol Clients Give Back August 10, 2015
- “Kick Your Eating Disorder’s Butt!” July 29, 2015
- Take-Aways from Our Time in the Wilderness July 21, 2015
- Beyond “He” and “She”: Teens and Gender Identity July 20, 2015
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