Dietitian Seasonings &
to the show notes for Jill and Meredith's Podcast: Dietitian Seasonings & Therapist Reasonings!
Whether you are just starting in the field of eating disorders or a seasoned, wise clinician, everyone needs support, guidance and advice once in awhile.
What is our podcast about?
This podcast is hosted by dietitian Jill Sechi and therapist Meredith Riddick, eating disorders specialists supervisors with A Collaborative Approach. This podcast is intended to support, educated and validate clinicians in the eating disorders field; emphasizing the team approach as best practice and encouraging evidence based care.
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Episode 0: In The Beginning
In this episode (episode 0), we introduce therapist Meredith Riddick and Dietitian Jill Sechi, certified eating disorders specialists supervisors with A Collaborative Approach. Meredith and Jill share their story of when they first met and began collaborating together in the field of eating disorders. Meredith introduces Jill and Jill introduces Meredith elaborating on work experience, time in the field and how they developed their expertise. In this brief episode we hope you get to know Jill and Meredith a little better as they begin their journey in the podcast world.
Episode 1: Give Me One Good Reason to Collaborate
“Team communication and collaboration are essential to prevent confusion and misunderstandings and to reinforce a unified message (Alexander & Treasure, 2012, p.146)." In episode 1, therapist Meredith Riddick and Dietitian Jill Sechi dive into their take on a collaborative approach and why it is important to promote a unified message. They talk about how having a collaborative team approach can be very beneficial, and how not having a collaborative approach can end up being problematic. Meredith and Jill also go into the different challenges when trying to collaborate with different clinicians, and how to face those challenges head on while still "staying in your lane." They also discuss the different themes of collaborating and how to utilize these themes in your practice daily. We hope you get an understanding of why we are A Collaborative Approach, and hope to spike your interest into our next Episode 2: Part 1 of the Ten Commandments.
Episode 2: Part 1 of the Ten Commandments
In this episode, Meredith and Jill talk about their first five commandments of collaboration. If you are thinking about implementing a more collaborative approach in your practice, this is a great episode to listen to. They talk about five different "commandments" that they live by in their private practices in order to maintain a healthy relationship with the client and other clinicians on the treatment team. Meredith and Jill go into how communication, respect, honor, and honesty are all used throughout the commandments. They go into what each commandment means, importance and how to avoid "disobeying" each commandment. We hope that you leave this podcast with a little direction on how to begin your collaborative approach, but we hope to give you more direction in our next Episode 3: Part 2 of the Ten Commandments.
First Commandment: Thou shalt talk to one another.
Second Commandment: Thou shalt not allow false testimony of other providers.
Third Commandment: Thou shalt honor treatment team as best practice.
Fourth Commandment: Thou shalt not covet each other's profession.
Fifth Commandment: Thou Shalt not commit treatment team adultery.
Episode 3: Part 2 of the Ten Commandments
In this episode, Meredith and Jill talk about their second half of the Ten Commandments for Collaboration. They continue to go into what each commandment means, , how to apply, and how to avoid "disobeying" each commandment. If you missed the first half of the Ten Commandments of Collaboration Meredith and Jill talked about those in Episode 2. If you have already listened to the first five, give this podcast a listen to get the full picture and learn how to put all the commandments together. Meredith and Jill strongly believe in and practice these Ten Commandments for Collaboration, and use them as their backbone in their practices. Stay tuned for Episode 4 as they dive deep into Body Image from a dietitian and therapist perspective.
Sixth Commandment: Thou shalt watch out for treatment bias.
Seventh Commandment: Thou shalt not misuse the name of Recovery.
Eighth Commandment: Remember major events and keep them holy.
Ninth Commandment: Thou shalt not throw in the towel with other providers.
Tenth Commandment: Thou shalt not steal the thunder of other providers.
Episode 4: Body Image, Diving Deep
In this episode, Jill and Meredith dive deep into body image and even divide into three different parts. They both discuss body image when working with clients, their own body image, and what the treatment provider roles are and how to address them. Meredith and Jill both go into the attitudes and emotions around body image; when to address body image in your sessions, what to engage in, and how to engage from a dietitian's and therapist's perspective. When discussing their own body image, they talk about how they personally deal with body image in the client/clinician relationship. They also go into clinician's roles and the education that is helpful to provide depending on their scope of practice. Do you as a clinician know how to handle body image? Is it realistic to always have a positive body image? Listen to our take on body image and how we as seasoned clinicians deal with body image in the field of eating disorders.
Episode 5: You're fired!
How do you feel when a client doesn't respond well to your practice? Have you ever been fired by a client? If so, how has this made you feel? Many can feel disliked, which is a feeling that no one wants to feel. In this episode, Jill and Meredith discuss how they feel and deal with clients that "fire them." They go into their own experiences and how they deal with a client moving on from them, or even maybe a client never clicking with them in the beginning. They talk about signs that they look out for based on their own experiences, that usually lead to being "fired" by their client. Tune in!
Episode 6: Tigger and Eeyore
Tigger and Eeyore? You may be wondering what in the world this episode could possibly be about. Instead of Tigger and Eeyore, could we be talking about anxiety and depression? In this episode, we go into an overview for how these topics show up for our clients. Meredith talks about the diagnostic criteria for anxiety and depression, she explains the differences in both of them, and goes into what to look for in sessions. Jill goes into how she sees anxiety and depression and how it can affect a client's behaviors around food. Did you ever wonder what a therapist might know verses what a registered dietitian might need to know when having clients that struggle with anxiety or depression? If so, tune in to Episode 6 and let us know what you think!
Episode 7: Let's Talk about Sex, Baby!
In this episode, Jill and Meredith talk about how eating disorders can impact intimacy. They discuss both physical and emotional intimacy as well as multiple examples of intimacy such as sex, being open and honest, or being vulnerable with friends and family. Intimacy concerns can come up in multiple ways with clients and you may be unsure how to approach it. Jill discusses how intimacy concerns can show up in nutrition sessions and the impact it can have on the client's relationship with food and or their body. Meredith talks about how it can appear in therapy, when addresses it in session, as well as and attachment therapy and how it can be used to predict a client's adult relationships or a client's eating patterns. How can a client's relationship with food mimic their relationship with people? How does a dietitian handle intimacy concerns? What about a therapist? Why is it helpful for a therapist to share intimacy concerns with a dietitian or other members of the treatment team? How can a therapist collaborate with treatment team members regarding this topic without disclosing too much information? Listen to Episode 7 to get answers to these questions and learn how seasoned clinicians treat intimacy concerns in the field of eating disorders.
Episode 8: Part 1 Are we a little OCPD about Dxs in Tx?
Have you ever had a client feel like they are being labeled or judged when they are diagnosed when an eating disorder? Do you tell the client what eating disorder they are diagnosed with? Do you know the criteria for all types of eating disorders? In this episode, Meredith and Jill discuss the importance of diagnosing a client with an eating disorder and basic criteria that distinguishes anorexia nervosa (AN), bulimia (BN), and binge eating disorder (BED). The more you know the each eating disorder diagnosis, the better you are to serve the client as each diagnosis has a different evidenced based treatment. Often we see that a client struggling with bulimia gets misdiagnosed with binge eating disorder. Why? What role does a dietitian play in diagnosing eating disorders? This episode will answer those questions and so much more in episode 8. In episode will focus on AN, BN, and BED, but stay tuned for episode 9, where they will continue this discussion on other specified feeding or eating disorders (OSFED), avoidant restrictive intake disorder (ARFID), and unspecified feeding or eating disorders.
Episode 9: Part 2 Are we a little OCPD about Dxs in Tx?
In episode 9 part 2, Jill and Meredith continue the discussion about different eating disorder diagnosis, focusing on other specified feeding or eating disorder (OSFED), avoidant restrictive intake disorder (ARFID), and unspecified feeding or eating disorder. This could be a possible diagnosis your client may receive if they are struggling with an eating disorder, but doesn't quite fit the diagnostic criteria of anorexia nervosa, bulimia nervosa, or binge eating disorder. Examples may include atypical anorexia, purging disorder (without bingeing), night eating syndrome, etc. They review different features of ARFID to be mindful of as well as some treatment strategies that may be used. This is a good listen to prepare you for upcoming episodes that will discuss the treatments more in detail. Listen in and let us know if this helped you gain a better understanding of Dx in ED Tx!
Episode 10: Perfection vs. Obsession
In Episode 10, Jill and Meredith dive in a good discussion about anorexia nervosa (AN) and obsessive compulsive disorder (OCD). Whether you are a dietitian or a therapist, it is important to know comorbidities that can occur with eating disorders; OCD is a major one. AN behaviors and OCD behaviors often look very similar and can easily be confused. Jill and Meredith help clear up any misconceptions there may be about this by defining OCD and providing examples of OCD behaviors, discussing the similarities and differences in AN and OCD behaviors and treatment, and providing examples of features that would help distinguish OCD versus AN when it comes to excessive exercise, restriction, eating behaviors, and anxiety around food. Lastly, Jill and Meredith talk exposure response prevention (ERP), a treatment approach for each diagnosis. Do you know when to diagnosis AN versus OCD? Is it possible for a client to be diagnosed with both at the same? Or do they have to be diagnosed separately? Does the therapist or dietitian do ERP? What is the therapist's role in ERP. What about the dietitian? Are there differences in the ERP approach for each diagnosis? You'll know the answer to these questions by the end of the podcast.
Discussed in this podcast:
The starvation study (click here! to read it)
Peace of Mind (non-profit organization whose mission is to help improve the quality of life of OCD sufferers): link to their website
Episode 11: The Trials of Termination
In Episode 11, Jill and Meredith discuss the process terminating a client. They compare how they handled terminating clients when when they were first starting out versus now, as more seasoned clinicians. They provide examples of reasons they have needed fired clients, both in the past and now. Do you fire a client if they require a higher level of care but refuse to go? Do you fire a client if they refuse to see a therapist, medical doctor, and/or dietitian, and will only continue to see you? They will review various options you have in different instances. Jill and Meredith end the podcast with discussing "following your gut." knowing your own limits as a clinician, scope of practice and ethical boundaries and requirements in your profession. Listen in to learn more on how to handle this difficult situation!
Episode 12: Meal Plan Mayhem
In Episode 12, Jill runs the show by discussing meal planning and the pivotal role it plays in eating disorder treatment. When struggling with an eating disorder, clients often become out of touch with their own biology. Jill talks about the dietitian's vital role in helping a client get back in touch with their biology and how meal planning in an important tool the dietitian uses to support a client return to normalized eating. She reviews various types of meal plans that will help dietitians in the field understand different approaches to meal planning that can be used with clients who have different needs. Meredith provides her perspective as a therapist on what a dietitian does and her understanding of various meal plans interventions she has seen. This podcast is a great listen for dietitians who may be newer to the field, or new to outpatient after time in higher level care, or even a more seasoned dietitian in need of a good review on the topic. This podcast is also great for therapist to understand more about the role the dietitian plays on the treatment team and the role the meal plan plays in treatment!
Episode 13: Resistance: The Attempt to Prevent Something by Action or Argument
In Episode 13, Jill and Meredith discuss resistance when working with clients struggling with eating disorders. They review the definition of resistance, the function and meaning of resistance, and review methods of dealing with it from both the dietitian's and the therapist's perspective. Do you know what resistance sounds like in a session? Resistance comes in many different forms and in this episode you will hear multiple examples to be able to better recognize when it. How do you handle resistance when it appears in the room? How to you help a client work through their ambivalence of wanting to stay in their eating disorder and work towards recovery? Sometimes it means taking off your "expert hat" and learning into the resistance with them. This episode will help you learn how embrace your client's resistance and work with it!
Episode 14: Your Dieting Daughter or Mother or Father..
Often when working with a client struggling with an eating disorder, their main support system is usually their parent, sibling, other family member, or spouse. What if their main support is also dieting? What do you do? In Episode 14, Jill and Meredith discuss dealing with dieting parents, spouses, family members, etc. Do you know how to handle this? Do you educate the parent on dieting or try to convince them to stop? What if a parent is refusing to keep certain exposure foods in the house due to their own beliefs or behaviors around food? Jill and Meredith discuss cases and examples that will give you some insight on how to handle this as a dietitian or a therapist.
Episode 16: V is for Vacation (No, wait! Actually Vegan or Vegetarian)
In this podcast, Meredith and Jill discuss working with clients that identify as vegan and vegetarian during recovery from their eating disorder. Jill defines the differences between vegetarian and vegan and her thoughts on this from a dietary and health standpoint. Meredith reviews the role of a therapist in helping a client identify their reasoning behind this decision and how it may affect their relationship with food as well as their relationships. What are some reasons for a client to not be vegan or vegetarian? What are some reasons it may be appropriate for others? Does eliminating an entire food group impact a client's likelihood to recover from an eating disorder? In episode 16 you will learn how you can handle this as both a dietitian or a therapist!
Episode 15: Recovery Red Flags with Clinicians; Calling in & Out
It is not uncommon for clinicians working in the field of eating disorders (dietitian or therapist) to have gone through an eating disorder themselves. Many who have struggled with any eating disorder want to work in the field to give back and help others struggling with eating disorders. At what point in the recovery process are they ready to be in the field? Is it a certain amount of time? 1 year or 5? What are the signs that an individual IS appropriate to be a clinician treating eating disorders? What are the signs they are NOT appropriate? In episode 15, Jill and Meredith provide some insight on this touchy topic with hopes of providing guidance and supervision to those entering the field.
Episode 17: Bariatric Surgery, Slicing and Dicing: Understanding Bariatric Surgery and Disordered Eating/Weight Control
In episode 17, Jill and Meredith discuss bariatric surgery and disordered eating. Jill reviews the basics of bariatric surgery and how she handles clients who are wanting bariatric surgery from a dietary perspective. Meredith discusses her approach as a therapist, including why she works closely with the dietitian and areas she focuses on in sessions. How do you approach eating disorder recovery after a client has already had bariatric surgery? For client's who are wanting the surgery, do you take them on as a client? If so, do you support them on this decision or do you try to convince them otherwise? Is it okay for them to have bariatric surgery? Why it is important to be open minded as a eating disorder clinician when it comes to bariatric surgery as well as other topics outside of your beliefs and your field? Episode 17 will answer these questions and so much more. Listen in and enjoy!
Episode 18: So Tell Me What You Want..... What Ya Really, Really Want?
It is not uncommon for clinicians to have an "ideal clients" that they enjoy or feel the most comfortable working with. This could be a specific age group, specific diagnosis, family dynamic, etc. As a new clinician, how soon should you narrow down what type of client you see? If you become too narrow too quick, you could potentially miss out skills set you may develop working with a wide variety of clients. If you a more seasoned clinician, what are some other reasons for seeing a wide variety of clients vs. exclusively your "ideal client?"Jill and Meredith share their own experiences as eating disorder clinicians and supervisors when it comes to narrowing down your practice to your ideal client.
Episode 19: Jumbo Shrimp and Intuitive Eating "Meal Plans"
In Episode 19, Jill and Meredith discuss intuitive eating in the eating disorder recovery process. Jill reviews the function of a meal plan for clients struggling with eating disorder behaviors, which was discussed in detail in episode 12. She discusses reasons intuitive eating is often not appropriate for clients in high level of care and what that transition away from a meal plan may look once they step-down to outpatient. Meredith discusses her role as a therapist in this process and points on common misconceptions clinicians may. What are the signs that a client may be or may not be ready for intuitive eating? How does the transition look from a structured meal plan to intuitive eating? What are some instances that a client may temporarily return to using a meal plan once they are an intuitive eater? In episode 19, Jill and Meredith discuss this very important topic!
Episode 20: "Supper"-vision: What is it? And What it's Not
In Episode 20, Jill and Meredith discuss supervision in the process of becoming a certified eating disorder specialist such as a Certified Eating Disorder Specialist (CEDS) or a Certified Eating Disorder Registered Dietitian (CEDRD). Meredith outlines supervision required for a therapist to become a LPC or a LCSW. Jill describes how this differs from becoming a Registered Dietitian (RD) and the reasoning for hiring ED dietitian "residents" in her private practice. Together, Jill and Meredith review the requirements to become a certified eating disorder specialist as of Fall 2019 through the International Association for Eating Disorders Professionals (iaedp) as well as why they find it useful to hold supervision together as a therapist and dietitian.
Episode 21: Compassion vs. Colluding
In episode 21, Meredith and Jill discuss the difference between compassion vs. colluding when working with a client struggling with an eating disorder. Compassion is used to help the us connect with the client and validate where they are at in their recovery. However, clinicians must continue to push and hold the client accountable to the recovery process. How does a clinician avoid aligning with the eating disorder? What are signs that we are colluding vs. being compassionate? What are reasoning clinicians will often collude with a client's eating disorder? Understanding how to give compassion rather than collusion is vital to being an effective clinician.
Episode 22: Client Case Conceptualization
In episode 22, Jill and Meredith discuss the importance of initial assessments with client and why properly conceptualizing your client is crucial for treatment planning, providing evidenced-based care, and building your confidence as a clinician. They discuss how case conceptualization differs as a therapist versus a dietitian. Do you know what questions to ask? What about observations of your client should you be aware of? Listen in as Jill and Meredith review this very important concept!
Episode 23: New York City?
This is a special episode where Jill and Meredith express gratitude to all of the amazing listeners of this podcast! They share a message from a listener who left a message which inspired them to take a pause to say THANK YOU for listening and keeping them motivated to keep the podcast going. Jill and Meredith share details about their upcoming presentation at Eating Recovery Foundation Conference on October 11, 2019. Come out and see them!
Episode 24: Forming, Storming, and Norming
In Episode 24, Jill and Meredith discuss group therapy. This episode covers so much information about what to expect when forming groups such as how people interact in groups, what clients can get out of groups, how groups differ from individual sessions, and how they can be helpful or harmful. Jill and Meredith also review different groups types (support, process, educational, open vs. closed) and how their groups have differed when they have co-led groups vs. leading them alone. How do you get people into groups? What are different ways to advertise groups? How many people should be in a group? What are ideal times to have groups? How long do groups typically last? What are some expectations to have for an ED group? Listen in to episode 24 and learn so much useful information about group therapy!
Episode 25: Fat vs Fat
In this episode, Jill and Meredith discuss why our clients want to know the ins and outs of nutrition and how to maximize their health, despite this fixation being the very thing keeping them unhealthy. Clients often come in wanting help sticking to their ‘perfect’ self-prescribed diet plan, not realizing that this strict plan is the very reason for their binges. Meredith explains why it’s important to dig deeper into your client’s reported foods, especially if they’re not seeing a dietitian, and how this can lead to further reporting of behaviors. Jill explains how nutrition education and guidelines can be presented to encourage food freedom, when at one point the same nutrition guidelines were construed into an eating disorder.
Episode 26: Stay in Yo Lane
With scope of practice boundaries, dietitians and therapists at times "cross over" to the other's area of expertise. We call this boundary a "white picket" fence. Dietitians may talk about skill work to enhance what the therapist reviews in session and a therapist may gently talk about meal planning concepts. Meredith and Jill strongly believe that to be a well rounded clinician one must "learn outside" their typical practice area.
Episode 27: Proactive vs Reactive
We often go into the field because of a strong desire to help others- but when does this desire get in the way of ethical care? Boundaries- holding ourselves accountable for our clients and ourselves. We discuss how to be flexible with boundaries so we can accommodate clients while maintaining our needs. As our needs shift, so do our boundaries, and therefore our ability to accommodate clients! Maybe the value of adding more clients is less than the value of having a day to yourself. Maybe our care will be more effective if we’re well rested. As technology keeps us ever connected, we explore how we can separate our personal lives from our clients’ care. What about the dreaded moment when you bump into a client out of your office? With the holidays approaching, gift giving comes with it. We navigate these sometimes hard conversations with proactivity- not reactivity.
Episode 28: Faith vs Fasting
Does religion ever come up in your sessions? How can you discuss it ethically, especially if their recovery is woven into their religion? Maintaining your faith separately from your client’s session is oh so important. Training and certification are available for those who want to specialize in faith-centric treatments. Meredith and Jill discuss using religion to advance treatment when the client is wanting fait based practice. CBT and gratitude through religion can help repair relationships with food by reframing thoughts. Learning about religions is important to better know the client and their value system. Self disclosure around religion can open new boundaries that need to be set. Faith based fasting can often be influenced by an eating disorder, and working through this challenge while being mindful of their religious values is necessary to respect the client and continue their care.
Episode 29: Happy Holidays!
Holidays can bring stress and busy schedules, family and food. With that, eating disorder thoughts and behaviors often increase. Meredith and Jill discuss how these stressful events be utilized as tools to encourage learning, grow in recovery, and challenge food rules appropriately. It is important to give clients skills to navigate family dynamics and diet culture over holiday meals. Clients often let appointment frequency decrease, which can promote challenges in skill enhancement. Holidays can also bring up feelings of grief for emotional events from the year and can be overwhelming for perfectionist clients who try to do it all. It’s important to stress that clients need to prioritize self care- including attending appointments and setting boundaries with family.
Episode 30: The Tortoise and the Hare (the true story never told)
Impulsive vs controlled personalities can influence a person’s experience with an eating disorder. Perceived impulsiveness can actually be malnourished-induced binges. Comorbidities can also influence how a person's impulse vs control appears in the session. DBT is commonly used for those who need help with impulse control, and RO-DBT is used for those that are overcontrolled. Meredith touches on the different skills taught in each therapy. Both involve coaching and frequent sessions to build strength in the skills learned. On the nutrition side, impulsivity is countered with structured meal plans and planning ahead when emotions are low. For overcontrol, structured meal plans are also used to challenge food rules and portioning. Visual guides, such as the plate method or eyeball measurements, are often used to encourage flexibility with food. Collaboration is essential to merging the two fields so that clients can fully understand what is asked of them and how they can apply it to recovery.
Episode 31: Ethical Dilemmas
Alright y’all, this one’s important. Today we talk about ETHICS! Boundaries are so important to hold. As clients express their respect and trust, it can be easy to be pulled into an unethical relationship. How do we handle a client’s advances? We can express gratitude for the compliment, and remind them that this can feel like a personal relationship, but it is professional and we are unable to spend time with them outside of session. Maybe they have a skillset (carpenter, lawyer) that you need, but these are still considered dual relationships. Sometimes our clients might know our children from school- we can bring up that we may be seen at their school and discuss how we can keep our clients comfortable with this connection. Supervision needs to be kept as just that- supervision! Don’t ask questions or talk about clients on social media. We explore how to practice within our scope and why it’s important to stay in our lane. Quick note taking and using evidence based practice are often looked over when thinking about ethical guidelines.
Episode 32: It's not just about "control".....
Meredith and Jill talk about control- and why it’s a blanket statement for eating disorders, even though it’s used by many. “Oh their eating disorder is just about control.” Well, of course it is! But, what’s underneath that a client is attempting to control? It’s really about managing their emotions after trauma, finding order in the disorderly, feeling special, lack of trust, etc. So when you’re collaborating with a clinician and you say your client developed their ED to gain control, that term includes so many possibilities- get specific! Or if you are not sure, seek supervision or work on learning more about the complexities of eating disorders treatment.
Season 2, Episode 1: Evelyn Tribole on implementing Intuitive Eating when working with a client struggling with an ED- Part 1
Evelyn Tribole has co-written an updated version of Intuitive Eating, available June 23rd, 2020.
How do you know your client is ready for intuitive eating when they have been in the throws on an eating disorder? Please welcome our first guest on our podcast Ms. Evelyn Tribole, registered dietitian who co-authored THE book Intuitive Eating!
In this episode, Evelyn discusses the importance of supervision for clinicians when providing guidance on the concepts of intuitive eating process. Evelyn describes IE as an important goal that the client knows they can “recover to.”
Questions she asks clinicians she supervises AS WELL as clients she works with: “Why do you have the belief you are ready for intuitive eating? And what informs you of this belief?
Supervision is imperative as knowing how to provide guidance to your client goes well beyond any intellectual knowledge that you have. Many have read her book, but supervision provides guidance around the experience of supporting your clients during this process.
Intuitive Eating has a few very small studies around the implementation specifically with eating disorders. Many more studies need to be performed! So where do you start?
Questions to ask your clients: “What are they capable of doing?” Can the client know and “listen” to their own body? Can they adequately respond to their body? Those in the throws of their eating disorder need a nutrition rehabilitation meal plan. BUT you can provide some insight into concepts of intuitive eating when they are on more structure. Questions you might ask your client to build intuitive eating awareness are “How does this food feel in your body?”, “How did it satisfy you?”, and “ What were you experiencing as you ate this food?”
Generally a client needs structure. Evelyn describes this as the body being ravaged by the eating disorder and they need a CAST first to stabilize their eating behaviors.
So what are the indicators your client may be more ready? What Evelyn describes as “Free Range Intuitive Eating?”. You will only know this when you have met the client where they are and have provided baby steps along the way. This requires a certain skill level of the clinician (which can be garnered through experience and the supervision process.)
Evelyn also discusses the Cognitive Somatic Distortions that come from eating disorders. When a client does not own their own truth, confusion ensues, fear develops and a complete mistrust of food sets in .
When intuitive eating is introduced too fast Meredith describes this as “drinking from a fire hose.” Baby steps are so important. A question Evelyn asks her clients is “Why do YOU want to recover?”
An important aspect of supervision and understanding how to implement in OP, RTC/PHP or IOP is understanding weight stigma, fat phobia, social justice and thin privilege. This is evident by “food addiction” concerns many clinicians continue to embrace. She describes this as a way of fear mongering. Evelyn strongly feels clinicians need to be well informed on the Health At Every Size concepts and examine your own biases or as Meredith discusses at “least be aware” and discuss in the supervision process. How can you effectively validated a client’s experiences when they can’t fit in an airplane seat for example.
Evelyn wishes clinicians understood that Intuitive Eating is about rational thought, instinct and understanding how emotions play a role in the eating process. The framework of IE is self care.
She feels many clinicians in the field know and understand the Intagram or version of Intuitive Eating and do not know that it actually has 120 studies and counting and is based on many constructs of human development and theories. She feels especially dietitians are not taught the unethical and poor effects of dieting in school or internships. Evelyn discusses that Intuitive Eating is not an opinion or a belief and finds that many clinicians make assumptions without being informed (reading studies, reading the book or supervision process).
In January, Evelyn is providing Intuitive Eating education that is more eating disorders informed (as not all professionals that learn Intuitive Eating desire to be in the eating disorders field). She feels with IE, clinicians need to be at least informed about EDs and HAES just as they would with trauma if working with ED clients.
SUPERVISION is NEEDED:
Supervision provides the canvas for the “art” of Intuitive Eating implementation in the eating disorders population. Learning about Intuitive Eating is imperative but through working with clients with eating disorders you begin to learn the nuances. The supervision process provides the confidence and appropriate implementation of skills when working with eating disorder clients.
Evelyn also strongly feels in order to work in the eating disorders field and appropriately provide guidance with Intuitive Eating, the clinician must heal their own unresolved issues with eating. You can “do harm” to the client as well as most only take a client “as far as the clinician has gone” in their own relationship with food.
The more the clinician is skilled at understanding their own body and how they feel, this can effectively inform us of the questions and generally inform the work that is provided in session with a client. When the clinician is able to effectively “see, hear and affirm ” a client this is a huge step in the recovery process. These skills can effectively be learned through the supervision process.
Evelyn does provide a small amount of supervision through her Intuitive Eating courses, however she strongly feels that if a clinician is going to work with eating disorders the clinician needs to have supervision and was happy to hear that this was required to become certified as an eating disorders specialist. This is a new concept for dietitians overall as continued supervision is not required to become fully licensed or registered.
Season 2, Episode 2: Evelyn Tribole on implementing Intuitive Eating when working with a client struggling with an ED- Part 2
Evelyn Tribole has co-written an updated version of Intuitive Eating, available June 23rd, 2020.
In Part two with our guest Evelyn Tribole, Jill and Meredith discuss a therapist’s role in intuitive eating and interoceptive awareness, as well as how Intuitive eating can be used throughout treatment, adn how it can merge with a meal plan. It can remind therapists of trauma related practices in terms of body responses. Overlap in treatment is expected and actually a good thing! Congruence of practice is so important. Communication is key with treatment team members to have consistency in messages and correlation of care. It’s important to have a variety of team members to refer to that are skilled in their scope with Intuitive Eating. When treating eating disorders, “If in doubt, refer out” and “Know your scope” are Evelyn’s mantras!
Intuitive eating is often taught too soon in recovery from an eating disorder- before the client has made peace with food and connected to their body cues. So, should residential treatment centers recommend intuitive eating for their clients or discharge them on intuitive eating? Asking “How is your body ready for Intuitive Eating” and listening for concrete answers is essential in knowing their readiness. Wishy washy answers tell the clinician that they are not recognizing body cues and responding to their needs.
“We’re looking for nutrition rehabilitation- that’s a fact” Evelyn says as the goal form a nutrition standpoint at the residential level. Feeding your body and working towards recovery is the goal- even if you’re not ready to be an intuitive eater yet. Nourishment is self care! Intuitive eating practices can be implemented even on meal plans and if people need to distract themselves from body cues to get nourishment. A healthy mind, eating enough food, and flexibility are foundations for intuitive eating and must be instilled in the client before intuitive eating. Hunger and fullness can be swayed by an eating disorder. They might not be ready to be an intuitive eater, but you can talk about body trust and body kindness. Clients might be desperate to be intuitive eaters, and reject the structure of a meal plan. Discharging from an eating disorder recovery program is often when a person is most vulnerable and therefore needs a structured meal plan according to Evelyn.
Intuitive eating can be implemented one day at a time. Clients can learn that disordered thoughts may come up, and they can choose to nourish their body at the same time. Waiting until a client is ready for this stage to introduce intuitive eating will reduce some trauma around behaviors and give them confidence that they can recover and be free of behaviors. If it’s introduced too soon and have behaviors without the structure of a meal plan, they may feel like they’ve failed and get discouraged to continue the recovery process!
Intuitive eating gives clients something to recover to- a hope that with recovery they will learn to know their body and respect its needs. It can be a point of ‘failure’ if introduced too early and clients may lose hope. It can be talked about in residential areas as a goal and reason to follow a meal plan, as clients will be able to come off of a meal plan as they gain body cues and trust.
Season 2, Episode 3: Punk Rock vs Classical Music
In this episode Jill and Meredith discuss how to work with a clinician who has a different practice style than you. When clients come to you as a referral, they may expect the same style as their first clinician. Our intuition and judgement might tell us that our client needs a different approach, but our own discomfort may prevent us from following it. Sometimes we get feedback from supervisors or other collaborators that our style might not be working well with the client. When we refer, we want our clients to have a clinician that meets their needs,which includes considering the style or approach of the clinician.
Season 2, Episode 4: Meal Plan Anyone?
“Don't dietitians just make meal plans?” is like saying “Don’t therapists just give advice?”. It’s important that therapists be able to convey the essential role a dietitian plays in eating disorder recovery. You can explain that therapy is more effective when the client is not malnourished, the food piece is well educated and discussed, and eating patterns are regulated. Dietitians can aid in the recovery process by asking questions about their food intake, social aspects of food, medical history, body cues, eating patterns, where they eat, weight history, bowel habits, psychiatric history, and so much more! We also can search through the fluff of changing their eating patterns right before seeing a dietitian. We collaborate with the therapist to get a more thorough background of how their disordered eating affects their life. The therapeutic alliance is important in building rapport with the client just as this is important for a therapist’s relationship with the client. Sitting with the client when they’re not ready for change- not just expecting them to follow a meal plan immediately. This is why our services are called medical nutrition therapy, although we do provide nutrition education and guidance.
Season 2, Episode 5: Meredith, I need some advice!
In this episode, Jill and Meredith discuss the role of a therapist in eating disorder recovery. Therapy is not advice giving, friendship, conversation, or venting. It is based on well-studied theories and evidence based practices. Therapists will have one or several theoretical orientations that influence how they present in the therapeutic environment. Therapy encourages you to gain values, get introspection, and build confidence to make your own decision. “This is a process, not an event” as Jill says. Many clients expect to have a few sessions but may not expect treatment to be ongoing for more than a year. Sometimes clients get antsy to make big changes, and want to have immediate relief from symptoms. This can be handled by encouraging small direct steps between sessions until clients get the hang of the therapeutic process. Therapists help them to gain insight into their eating habits specifically, even if they have already had years of therapy to address trauma/anxiety/depression. The eating disorder may have been active and a uninformed therapist never screened, or thought through the lens of diet culture that restriction was an appropriate coping skill and saw dieting and self care. If setting the boundary that therapy is not advice feels uncomfortable, seek supervision!
Season 2, Episode 6: A Wrinkle in Time
In this episode, Jill and Meredith discuss what clients might experience when changing levels of care. Clients might start their treatment in residential and not yet accept the severity of their eating disorder. One purpose of a higher level of care is to move through ambivalence in a way that keeps them stable and safer than they would be at a lower level of care, even if they aren’t yet ready to completely face the struggle. In outpatient, Meredith describes work as “slow and steady” and “one step forward, three steps back”. Clinicians who start off working in higher level of care and then move to outpatient may experience slower client progress and feel ambivalence from the client. It’s important to meet clients where they are to avoid pushing clients away or focusing on setbacks rather than progress. In outpatient, a clinician should look at progress over a six month period rather than two weeks. When stepping down, clients will ideally have a discharge plan, relapse prevention plan, and be in contact with their outpatient clinicians before discharging. Continued support and communication with the client is important to solidify behavior change and continue to restore nutrition, as well as setting treatment expectations. Higher level of care can offer patients (and clinicians!) a more social environment to work and practice confrontation skills and validation from others.
Season 2, Episode 7: Diagnosing Dilemmas
From all the options a client might have for being diagnosed, how can you differentiate what a clients true diagnosis is? Diagnosis isn’t a label, it’s a key that can unlock treatment options. The DSM can have nuances that make diagnosing confusing. In anorexia nervosa, a diagnostic criteria is low weight. However, some clients are not considered as having a low weight, but show all symptoms of anorexia nervosa. In these cases, they will be diagnosed with OSFED- atypical anorexia. With children and teens, we use growth charts to determine usual body weight. If they are below their usual body weight, they will be considered to have anorexia nervosa. Clients who are in larger bodies have higher caloric needs, and many diets are at a low enough calorie threshold to spark anorexia nervosa. They may not be in a thin body to where all medical professionals recognize them as experiencing AN or think they’re ‘sick enough” to receive referrals to eating disorder treatment. Fixation on food, hypotension, and life disturbances are prevalent enough to warrant a diagnosis- even if the person does not appear malnourished or underweight. When determining higher level of care options, ask treatment centers about weighing procedures, mixed mileues, and weight biases of clinicians. Site visits are important to determine appropriateness of fit to the client’s individual needs, including having furniture that can accomodate the clients’ body comfortably without making them feel ostracized.
Season 2, Episode 8: Are You Still in Diapers?
Are you still in diapers? Meaning- are you a new clinician? New clinicians are often asked questions like their age and experience. These can be handled professionally and can be insight into the family’s beliefs and thoughts about treatment. It can be a sign of transference, ability to relate, and capability. When clients ask us about more personal topics, we can experience countertransference and pass judgement onto client for their boldness in asking these questions. As we gain experience as clinicians, we also gain confidence. The Dunning-Krueger effect explains the phenomenon where we think we know, then realize we don’t know, then finally realize we do actually know what we are doing. This is common in new clinicians who are learning about the vast information about eating disorders. As we discover more information exists, we begin to feel less competent until we dive into the information and study it thoroughly. It’s important to focus on the ‘why’ behind a client asks a question. Self disclosure after a question is asked is not always appropriate, and it may need to be redirected. Answering questions could build a friendship instead of a therapeutic alliance. Be curious about when and how you self disclose, and what it might mean about your own insecurities in the room. How can we best respond to these questions? Shutting down the question can harm rapport building. Meredith explains self disclosure as “We are humans before we are therapists or we are dietitians”. The therapeutic alliance is the biggest agent of change. Responding in a way that is humorous, engaging, and establishes good rapport can help a client feel heard, even if you do not want to answer the question directly. Dress for success is your motto if you notice patterns of initial meetings with clients not going great. Encouraging curiosity is helpful throughout the recovery process, including answering unwanted or inappropriate questions or comments.
Season 2, Episode 9: Are If I knew then what I know now with Amanda Holben, RDN
Please welcome our guest, Amanda Holben, RDN! Amanda is here to tell us what she wishes she had done differently at the beginning of her practice. She began her career at Remuda Ranch for several years and at Austin Eating Disorder Center, and eventually moved to Houston and opened her outpatient private practice. As she has a wealth of experience, Jill and Meredith ask her- what would you have done differently when you began practicing? Amanda wishes she had taken an abnormal psychology class to learn the lingo and have an in-depth view of mental health concerns. She also wishes she was more open to learning from clients and not feeling like she has to know the answers to everything. Jill explains that each client is an individual and it’s important to see their unique eating disorder traits, and Meredith explains that a messier recovery process is better than temporarily abstaining from behaviors. Reflecting on yourself after a session creates growth in the clinician and helps you face the clinician blocks head on. Tuning into a client’s non-verbal cues can help build trust and make the client feel heard; it’s important not to ignore non-verbal cues and to bring them into the room.
Season 2, Episode 10: Mommy and Me with Amanda Holben, RDN
In this episode, Jill, Meredith interview Amanda Holben, RDN about the transition from a hectic professional career to focusing on parenthood. Amanda feels that choosing to pause a career to focus on motherhood is a huge decision, but not the right decision for everyone. Amanda had a successful private practice, and found herself in the position where she could stop working and stay home with her daughter for as long as she can. Amanda feels that she can work at any time, but her daughter will only be a child for a set time. It also has allowed her to reconnect with herself and who she is outside of work. It also gives her a different perspective of the world outside of the anti-diet bubble. Giving herself a break from work allows Amanda to recover from burnout and return rejuvenated and restored. Perspective can shift once you’ve stepped away, and can see that clients who want to get better will get better.
Season 2, Episode 11: Burnout Anyone?
In this episode, Meredith and Jill discuss causes of burnout and how to recover from it, and even how to prevent it. What is burnout? Jill discusses that balancing motherhood, high clients levels each day, and multiple job responsibilities contribute to her burnout. Meredith discusses how life stressors impact stress levels about client load. Learning your own boundaries around how many clients to see per day and week, lunch breaks, and working location is a good start. Some people like low client loads per day, but work several days per week. Others prefer to have whole days off to balance work and life. Check in with yourself about how you’re handling a client load. While shifting boundaries around work, it can bring up fears that clinicians will no longer refer or business will slow. Moving towards values- be it time or family or rest- can improve overall balance and enjoyment of work. Knowing your strengths and using them can alleviate stress. Balancing more strenuous clients with less clinically impactful clients or setting boundaries around age or therapies used can preserve your strengths and make sure they are used to their full advantage. “Know yourself and now what your needs are” is the mantra to repeat if you’re a new clinician figuring out boundaries around work and life balance. Building a therapeutic relationship is important, and can be difficult if you take on too many new clients too quickly. Supervision and training can reduce burnout by validating the experience and finding solutions to problems a clinician is running into. Sometimes our feelings outside of session can bleed over into session, and therapy can be useful to work through big feelings outside of clients so it does not impact sessions. Be congruent with your recommendations and seek therapy if you’re struggling with burnout!