How Therapists Promote Diet Culture: An interview with Rachel Coleman
Curt and Katie speak with Rachel Coleman, LMFT, CEDS about what therapists should consider in working with clients who have eating disorders, the impact of society on body image, and how clinicians can increase their competency in an area many feel they are lacking. Why do so many clinicians feel under trained in treating eating disorders? How do societal views impact our client’s body image and what is the impact of diet culture? Does a lack of graduate education in eating disorders ethically impact our ability to treat eat disorders in a non-specialized practice? What’s missing from our understanding of eating disorders? All of this and more in the episode.
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Interview with Rachel Coleman, LMFT, CEDS
Rachel Coleman, LMFT, CEDS is a Licensed Marriage and Family Therapist and Certified Eating Disorder Specialist. Rachel received her Masters in Clinical Psychology from Pepperdine University, and shortly after began working at an Eating Disorder treatment center in Long Beach, CA. After five years of working as a Recovery Coach, Primary Therapist, and Program Director in treatment, Rachel shifted her work into private practice where she aids her clients in embodying daily the principals of eating disorder recovery. Rachel is also a certified Dialectical Behavior Therapist and has completed extensive training in the Intuitive Eating dietetic approach. She is a former board member of the International Association of Eating Disorder Professionals, through which she is certified as a Certified Eating Disorder Specialist. Currently, Rachel practices out of her private practice in Orange County, CA.
In this podcast episode we talk about working with clients who have eating disorders.
In honor of Eating Disorder Awareness week, we spoke with Rachel Coleman about the nuances in treating eating disorders and how clinicians can most effectively treat these clients within private practices.
“We live in a society obsessed with diets and bodies. And so I think it’s very easy for subconscious beliefs about food and bodies to infiltrate sessions, because it’s subconsciously in us and so it can come out in our language.” – Rachel Coleman
What do clinicians do when therapeutic interventions might trigger eating disorder behavior?
- Many interventions call for physical activity that might trigger eating disorder behavior or feelings in clients.
- If a client wants to participate in a physical activity intervention, consider their motivation.
- Ensure that a client has multiple tools in their anxiety toolbox.
- Be mindful if the modalities and treatment recommendations are based in fat phobia or weight stigma.
How can clinicians assess their clients for an eating disorder?
- Eating disorders can present meeting full DSM-V criteria or, in many cases, seem at the “subclinical” or mildly clinical level.
- Evaluate how your client feels about societal messaging and the impact it might have on them.
- In assessing clients, look to determine the impact of behaviors and patterns on daily functioning. If client’s are sacrificing other values to focus on weight or body, it should be discussed.
How can clinicians increase their education in treating eating disorders?
- Clinicians need to do their own work surrounding their bodies and internalized messaging.
- Therapists should focus on learning about the complexities of eating disorders and the social justice movements that surround weight stigma and fat phobia.
- Familiarize yourself with the ideas of body trust, body neutrality, and health at every size.
- Many treatment centers offer free webinars to educate clinicians in eating disorder treatment.
“Let’s face it, all of our clients have a body. And all clients are therefore going to have to figure out a relationship with their body regardless of eating disorder
diagnosis or not.” – Rachel ColemanHow Therapists Promote Diet Culture: An interview with Rachel Coleman
What are the ethical and legal considerations in treating eating disorders in a non-specialized private practice?
- Always get consultation.
- Some clients might present with “subclinical” or mildly clinical levels of an eating disorder.
- There is a difference between asking questions and treating the answers.
- Clinicians should encourage clients to see a medical doctor when necessary.
- Working with dieticians and medical doctors to create a holistic team, best serves the client.
- Clinicians should be aware when to refer to a higher level of care.
- Therapists should limit self-disclosures
How does Diet Culture impact our clients?
- Diet culture is a mindset and system of theories we all exist in, that credits a person’s shape and size as the primary indicators of health and moral superiority.
- When bodies don’t meet these “standards” of beauty as societally defined, they are often oppressed.
- Messaging about dieting and our bodies is inescapable in our society, so it’s easy for subconscious beliefs about food and bodies to infiltrate sessions.
- Therapists’ self-disclosures should be limited and focus on affirming client’s experience.
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Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
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Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Curt Widhalm 00:00
This episode of the Modern Therapist’s Survival Guide is brought to you by SuperBill.
Katie Vernoy 00:05
Interested in making it easier for your clients to use their out of network benefits for therapy. Super bill is a service that can help your clients get reimbursed without having to jump through hoops. Getting Started as simple. Clients complete a quick HIPAA compliant signup process and you send their super bills directly to us so that we can file claims with their insurance companies. No more spending hours on the phone wrangling with insurance companies for reimbursement. Super bill eliminates that hassle and clients just pay a low monthly fee for the service.
Curt Widhalm 00:34
Stay tuned for details on SuperBill’s therapist referral program and a special discount code for your clients to get a free month of service.
You’re listening to the modern therapist survival guide where therapists live, breathe and practice as human beings to support you as a whole person and a therapist. Here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 00:57
Welcome back modern therapists. This is the Modern Therapist Survival Guide. I’m Curt Widhalm with Katie Vernoy. And this is the podcast for therapists about the things that we do in our office. Sometimes the work that we do with our clients and always exploring the ways that we can do better for our profession and helping with clients. And this week is Eating Disorder Awareness Week. And it’s been a while since we have talked about eating disorders here on the podcast, and wanting to explore a little bit about some of the ways that we can potentially know where our limits are in working with these populations. We do have a couple of earlier episodes that we’ll link to in our show notes. But today we are joined by Rachel Coleman LMFT, CEDS, I went to grad school with Rachel so somebody that I have known for quite a while but bring it on the experts to talk about things that we don’t have expertise on ourselves. So thank you very much for joining us, Rachel.
Rachel Coleman 02:03
Thank you for having me. This is a fun 1520 year reunion here. I don’t know how long is it? Think it’s getting up there?
Katie Vernoy 02:12
Yeah. Oh, wow. So excited to have you here. And for this conversation. The first question that we ask everyone is who are you? And what are you putting out into the world? Sure.
Rachel Coleman 02:23
Like Curt said, my name is Rachel Coleman. I’m a licensed marriage and family therapist, and that CEDS is a Certified Eating Disorder Specialist. I have a private practice down here in Orange County, California. I treat eating disorders and all the underlying issues that present along with eating disorders. What am I putting out there in the world? I mean, I suppose I’ve dabbled in social media. But really, my passion is just in one on one, individual therapy, I really believe in that secret therapy space where clients can identify and break their personal and family legacies around bodies and food and diets. I really believe that helping that what we would call in our line of work the identified patient heal really has a ripple effect. It helps the older generations do their own deconstruction and healing. And then it also I’m hoping changes the future of the next generation. So I really do believe in that that beautiful therapy relationship and the ripple effect that occurs when a client is able to do that awesome work.
Curt Widhalm 03:32
And one of the first questions that we usually ask is for a learning place, this is not to necessarily shame anybody but the experience that you have. And I’ve maybe even in grad school, I think you were working in eating disorders. If I remember our practicum classes correctly, that you put around for a while, what do you see that therapists get wrong in working with eating disorders?
Rachel Coleman 03:59
I mean, I think that therapists and everyone live in a very diety culture. We live in a society obsessed with diets and bodies. And so I think it’s very easy for subconscious beliefs about food and bodies to infiltrate sessions, because it’s subconsciously in us and so it can come out in our language. And diet culture is a term that’s thrown around a lot. So I can give your listeners a little bit of a definition. My definition of it is, it’s a mindset and it’s also a system of theories that we live in, that really credits a person’s shape and size as the primary indicators of health and also a moral superiority. So basically, with a diet culture, thiness is valued above other body types. Foods are usually described with moral terms like good or bad, healthy or unhealthy. And unfortunately, bodies that don’t meet this projected ideal of beauty they have often been oppressed. So when we are just growing up and still living in a culture that holds this belief system, it can easily be something that we don’t even realize that we’re drinking the Kool Aid of, and it can come out in our conversations or in our perspectives. So often I hear unfortunately, clients share with me things that therapists have said that were really kind of harmful or hurtful, even if it feels like it’s nothing big. So for example, I’ve heard people share that therapists have discussed working out or going to the gym and sessions, or like I said, therapists are on social media these days. So sometimes they will post their workouts or their runs. Even if a client is talking about exercise or going to the gym, even a little like typical quip in our society of like, Oh, I’m so terrible about going to the gym, brings in that moral superiority in a very subconscious way. Or even kind of walking across the room to like, open the door, get a book being like, well, at least I got my steps. And, and I think anything that kind of once again, perpetuates this belief system of working out is good or not working out is bad, or anything like that automatically becomes a place where maybe a client doesn’t feel safe, because that’s the exact work that they’re trying to do. This also comes out with food, you know, if therapists are talking about their chronic dieting, or saying phrases like, oh, I struggle with my weight, I get it. Or feeling like foods, if they don’t believe that foods are neutral, and they are coming out in sessions with conversations about oh, trying to eat healthier, or foods are good or bad. Basically, sharing personal experiences about fad diets, or even lifestyle changes. And using air quotes. Anything that kind of just continues to perpetuate these beliefs about food and bodies can really create a space where a client doesn’t necessarily feel safe to interrupt any patterns or behaviors that they have been suffering from. So overall therapists not having done the work themselves, to deconstruct their beliefs can come out in those conversations.
Katie Vernoy 07:23
What you’re saying is, makes a lot of sense. And I’m finding the bias that I have from society coming up. And so I want to if if it’s okay with you, I want to play with this a little bit, because there’s a question that I’ve had for a while. And it’s hard to know how to manage it. I was in grad school longer ago than the two of you were. And a lot of the especially around depression, a lot of the treatments were activity, making sure that you’re, you know, drinking enough water or eating appropriately, you know, kind of having enough food, but also having healthy foods. I mean, and I have my air quotes going to, I think it’s, it’s hard for me to know what is promoting health, being active is considered healthy. That was my understanding. I think eating foods that are nutritious and nourishing, I think is considered healthy. And so I can, I’m understanding that element of let’s not make this about moral judgments if we do things that are in alignment with what society calls healthy or good, but I’m, I’m struggling to identify how we support folks without that playing in and what what is okay to talk about, like, that’s, that’s hard for me to find that line.
Rachel Coleman 08:42
Mm hmm. I agree. And I, I do DBT. And in DBT, there’s a lot of similar types of modalities that we recommend. So I understand that. Absolutely. There is a fine line and some of those things are very, very helpful for combating depression. So yeah, yes, I think the the, the fine line that I always am navigating in conversations with clients when we’re trying to figure out self care, because that’s kind of what you’re talking about. Sure, is the motivation behind it. So I think often, if the motivation behind it is, well, I’m gonna go do those things because I am trying to change my body, or because I’m trying to pursue the weight loss, or because I, you know, one’s gonna hear quotes feel fat, then what you’re looking at is how do you deconstruct the motivating factor behind the behavior, rather than okay? There’s nothing wrong with going for a walk or a jog or going to the gym, especially if the motivating factor is it’s that endorphin release that helps ease the anxiety and there’s nothing necessarily about the body that’s coming into play. Or once again, if that is the only coping skill in the box for anxiety management, well, how do we brought in the skills within the box. Maybe here and there, there’s an exercise element to anxiety management, then there’s also 10 other things, so that it can be this just more well rounded whole person thing. And I think this is where if a therapist has done their own work, and then able to have some of these really deeper conversations with clients, they’re able to realize whether or not what they’re upholding in their modalities or in the recommendations, is based in any internalized fat phobia, in any weight stigma, and kind of is, what’s the ethical fine line that we’re helping people walk? Does that answer the question a little bit?
Katie Vernoy 10:38
It does. I have some more questions. But let’s dig deeper in, I see Curt ready to jump in here,
Curt Widhalm 10:43
You mentioned a couple of times about therapists doing their own work. And in this regard, and for many of us, the education that we received on eating disorders in graduate school was minimal, if anything, what some suggestions as far as doing your own work on this, that our audience might be able to walk away with?
Rachel Coleman 11:04
Sure, I mean, obviously, doing your own personal work on what are your beliefs about food bodies and weights, and doing that either in your own personal reading or journaling or therapy? And as far as you’re right, there is very little education. I think we got a one hour lecture. That’s all I remember personally. So it’s it’s definitely insufficient. And I think that absolutely doing more webinars, podcasts, taking any courses you can anything about the complexities of eating disorders, and also anything that focuses on the social justice movements surrounding weight stigma, that teaches cultural awareness and sensitivity towards viewing bodies and sizes, encourages this concept of Body Trust and body neutrality. Those are kind of modalities that we try to work from, how do you trust your body? And how do you honor your body, anything that’s aligned with Health at Every Size, which I know you guys have spoken on in the past, most even sought treatment centers regularly offer free webinars, virtually, there’s local IADEP, that chapters you can get certifications in intuitive eating. So you can do a lot of extra work on your own. I also recommend, obviously, if you’re interested in this field to start working at and even sort of treatment center work at the highest level of care that you can try to get in with because when you are in the trenches, in these inpatient residential settings, you’re going to get just an immersion of so much education. And that’s kind of where I started my work.
Katie Vernoy 12:41
It seems like there’s a lot more knowledge that a therapist would need to really be able to effectively treat an eating disorder. And I also know that there are a lot of folks that have disordered eating are fully immersed in diet culture, and have some of the kind of subclinical or mildly clinical levels of this that I think all therapists need to know. And it to me, I’ve had some clients who came in for something completely else, and then we’re on weird diets. And, and, and also hated their bodies and had really negative self talk really harsh, critical negative self talk. And so I’ve sought consultation and done other things to try to support that, and referred where appropriate, but I think the the pieces that were critical for me to know at first, were kind of this assessment of figuring out, is this someone that’s maybe drinking too much of the diet culture Kool Aid? Or is this someone that has an eating disorder and needs that more specific eating disorder treatment, you have some suggestions for clinicians, who are maybe needing to assess their caseload because you know, when we’re recording this, it’s the new year, you know, there’s a lot of people on diets and fats, and this and that. And so I think there’s, there’s a need to really understand and assess appropriately to as a start,
Rachel Coleman 14:06
I think you bring up a great point, it sounds like you’re doing awesome, work yourself, of just continuing to hold that space, because that’s let’s face it, all of our clients have a body. And all clients are therefore going to have to figure out a relationship with their body regardless of use for diagnosis or not. So I agree, and that’s why I also think that grad schools should absolutely talk to you about this way more, because your every this is something that’s going to come up with every single client regardless of their presenting problem. So yes, because all of our clients live in this world, and we live in this world, they’re constantly sending the messages to change their body, the impact of that messaging will vary. And so you’re right, you’re going to have to kind of evaluate where the client is on the impact of this messaging, and then the how much they’re applying this diet, culture messaging, when wherever we can just open up this therapeutic space to be a comfortable place for a client to process their connection with their body, their relationships. With the scale, the trust they have with their hunger and fullness cues, with their body size and shape, whatever past or present body insecurities that they have, and how it’s impacting their ability to function. Now, ways that they’ve used food to cope with those feelings, any internalized beliefs they have about their body from past bullying from childhood from parents, you know, what, what was it like at the family dinner table for them growing up was their family dinner table, and just all of the different layers of what how a client feels about food and their body, every client has to eat five, six times a day, you know, they have to learn how to dress their body, how to take care of it, how to get good sleep. So I think having a safe space with that neutral, that neutral energy is a really great space. So anyway, that kind of is touching on that piece. As far as the assessments concerned, I think you’re really looking at the impact of any behaviors or patterns on daily functioning. Anytime a client is choosing to focus on weight or body and sacrificing other things that are aligned with their value system, then it starts becoming something where, okay, obviously, this is becoming your priority. And I don’t think your priorities are in alignment right now with everything else that is really important to you and makes up your identity. And so we have to kind of make sure that then at that point, whatever these behaviors and patterns are, become some of our primary goals and focuses to treat. And if again, if that feels like it’s something that starts feeling it’s out of your scope, because the client feels out of control, they’re not able to pull back anything, they’re not able to easily make those tweaks and go oh, yeah, you’re right, wow. So curious, I’m going to try something different when it feels like it is fear base that they’re doing these behaviors and patterns, they can’t make those changes easily. It’s impacting their ability to be in social relationships, go to work, choose other things that are important to them. And then you’re probably looking at something that’s a little bit more deeply embedded
Curt Widhalm 17:03
In my experience, and I’ve gone to a lot of these workshops at various conferences and treatment centers over the years and have really noticed just kind of my sensitivity as a clinician to a lot of the things that you’re talking about. But it seems like if there’s three categories of people, the people who have the bare minimum of eating disorder, education, and then to the gold standard of eating disorder treatments, the CEDS, there’s kind of this dangerous place in the middle of thinking that you’re further ahead in the work, that I don’t know if I’m in that dangerous spot or not. But at least being aware of where that edge is.
Katie Vernoy 17:45
Yeah, you and me both buddy.
Curt Widhalm 17:48
It seems like this is a time that that’s really ripe to be making some of those mistakes that you’re talking about. And a big part of what we talk about on the podcast here is about being a little bit more transparent with your life. And you brought up social media earlier and some of the ways that clients might have access to therapists life in some of these ways before, do you think that this contributes to maybe some of that fear of treating eating disorders and a lot of the population is that having to look at ourselves in the way that we’re putting ourselves out there? It’s just easier to pretend that it doesn’t exist.
Rachel Coleman 18:25
Maybe Yeah, you’re right. There is a dangerous space. And yet, I’m absolutely not someone who’s like don’t even go there and leave it to the experts like, again, because all clients have a body, everyone is going to have to have some element of conversation about this. I think there are a couple of reasons why many therapists feel apprehensive about treating this and they’re not sure what to do and part of it yet is I think that a lot of people secretly know that maybe they don’t have peace with their own bodies, or they do have some of that secret fatphobia or they have their own struggle with free behaviors. And they’re, they’re concerned about their ability to stay neutral not have any transference or countertransference that are impacted their therapeutic relationship. So you’re right. I think it’s one of those things where it’s like, in order to feel like you’re navigating this, you do have to have a sense of peace and neutrality in your own personal life. That is really, really important. I also hear a lot therapists say, like, I could never do that, like I just like food too much or I just I just don’t get it and it’s like, Okay, again, no, I think whatever, whatever that fear is underneath that is probably something that needs to be healed yourself because you are human who also grew up in this space. I think the legal ethical pieces are the most probably concerning with treating eating disorders. I think that is where it’s dangerous probably to use your word and then also where people can really shy away because there is that medical liability that can present along with an eating disorder. And there’s, it’s so embedded in us to be like, check for safety, check for safety. And like, the first course we have in grad school is that law and ethics course which like, I think most people are like, nevermind, we’re not going to do this entire grad school program, this is almost like quit right that in there. You know, I think it becomes something where it’s very, it’s very scary to think, Okay, I am now treating someone who there potentially is a safety concern and medical liability on the line here. So while yes, that space, right there is I think we’re client. I mean, I’m sorry, I think that space right there is where therapists tend to completely shy away. And trust me, I consult nonstop with licensing boards and treatment teams, and there’s a lot more wiggle room than you think. We I also am almost always with a treatment team. There’s almost always a dietician on board and a medical doctor on board. And then most often that we are also referring to those higher level of care. So the impatient and anything to get them the stabilization needed so that we can continue treating outpatient. And then I also think that people under think them, and that is where the dangerous space comes in. Again, people kind of just think, well, you know that behavior is normalized in our society. So I’m not concerned about it. And they forget to ask questions about, you know, heart rates, or sleep or how much water clients are or are not drinking, or the clients are saying that they are eating out. But therapists aren’t asking, Well, how much are you eating? And what else are you taking? And they’re not asking the little detailed questions that if you start kind of having an awareness of how even shorter is present, then you’re able to realize, oh, this might actually be more severe, then my brain kind of caught on initially.
Katie Vernoy 21:42
I know for myself, when I’ve had clients that have started to have behaviors that were of concern, and I pulled out into a team I was, I was honestly surprised by some of the information that hadn’t been shared. Part of it is I’m not a medical doctor. I’m not a dietitian. So I’m not necessarily asking really, really specific questions. And my this is leading to my question. But like some of the medical questions, I don’t think to ask I’m not a medical doctor, but it sounds like you’re saying maybe we should. And so I guess the question is, how do we ask some of these questions and stay in scope of practice?
Rachel Coleman 22:21
I think asking questions is different than like treating the answer. Okay, you know, okay, so I think I often ask, how does your How does your heart feel when you sit or stand up? Oh, it’s funky. Okay, let’s go, let’s make sure you definitely go to your doctor, I want you to go to the doctor and have that conversation, and then I’m going to have you sign the release, I’m going to consult with the doctor because I think we need to make sure that that’s okay. Or if it’s a female, ask, when’s the last time you’ve gotten your menstrual cycle? Okay, it’s been three, four months. All right, you know, I want you to go to your doctor, an OB GYN and get that checked out. Because that’s, it can be a sign of malnutrition. And so I want you to make sure that that is ruled out or ruled in so we know how to proceed. And you know, how many laxes and diuretics are you taking again, this is just intake information for me, I’m not, I’m not just reading it, but I’m knowing what I’m what sitting on my couch. And I’m knowing what I need to recommend to do next.
Katie Vernoy 23:14
And maybe that’s the that’s the part that’s challenging, knowing what to do next. I mean, it’s easy just to say like, anything that’s wonky, goes to your doctor, and and so that that feels like, that feels very doable.
Rachel Coleman 23:25
And then get that release, get that release, because again, we’re I can’t read labs, right. So if a client gets gets the labs and is like, I got my lab work here, it is like that. That’s way out of my scope. So make sure that information is so because I need to ask the doctor what these numbers mean. And I need to know what the doctor so a huge piece of outpatient care with disorders is a lot of times on the phone consulting with other members of the team.
Curt Widhalm 23:53
And I changed the conversation a little bit here to the client end of things and why you see that people with eating disorders don’t necessarily seek out treatment.
Rachel Coleman 24:04
Yeah, I think there’s a huge shame cycle. That is, you know, in rotation here, a sense of going I am scared to talk about how out of control I feel about certain behaviors. And then I also feel a little protective of those behaviors, because they probably came into fruition to protect me from something protect me from weight stigma from trauma, they eased my anxiety. And so it feels like you’re asking someone to give up their greatest resource and also their greatest source of misery. And there’s, I think, a lot of shame that clients identify that they are in this cycle and they are kind of stuck in this space. And it’s it’s, it’s makes them hesitant, I think, to to seek out that treatment because they’re going to have to lay it all on the table and kind of figure out what they need to tweak.
Curt Widhalm 24:56
How do we as a profession kind of contribute to some of the those fears?
Rachel Coleman 25:03
That’s a great question. I’m sure there’s a sense of trying clients feel like we’re, we’re so hyper focused on the behavior, that we’re maybe pushing them to give something up that they’re not ready to give up. And so it feels like they have, they’re held accountable, which again, is that fine line of like, of course, we want them to feel like there’s some sort of safety and accountability in sessions. But we also don’t want to give them ultimatums or feel more ashamed. If they did struggle, that behavior in between sessions, so that then they’re going to be avoidant of coming in processing what’s going on. So then holding that safe space to say, this is really hard. This is a really, really challenging, complicated cycle to break. And I’m going to keep my fears of liabilities and legal and ethical stuff at the door. So I can hold a safe, neutral space in the room for you to kind of process through where you’re at and how we can continue to support you.
Katie Vernoy 26:03
To me, it seems like the risk elements are the things that therapists probably could get tripped up on pretty quickly, you know, especially if they’ve got a long standing client who’s showing up with some of these behaviors, they’re getting out of control. And I know, probably a number of therapists that are listening, you know, that was a pandemic thing. Clients that had been fine had an eating disorder long, long ago, all of a sudden, it popped back up during the pandemic, and now they’ve got this long standing relationship, and referring out feels a little bit daunting, and not advised. Right. And so I think it’s, for me, I think the thing that would be helpful is talking through some of that risk, like, When is it okay to kind of allow the client to be in their process? And when is it like no, no, this is a danger. Like, I need to take some big steps.
Rachel Coleman 26:52
I mean, I’m not a legal ethical expert here. Call your licensing board. I…
Katie Vernoy 27:00
But, but when would you call your licensing board, I guess is what I’m asking.
Rachel Coleman 27:04
I think what it comes down to a sense of like, is this client medically able to take care of themselves and safe in between sessions, that is 100%, a call to licensing board, I’ve been calling you right, the licensing board more and more and more since the pandemic started to like more than ever, because aces are more cute than ever. And one of the biggest challenges to treating as far as right now is that the inpatient residential high levels cares have two, three, maybe more month waitlists. So you have someone who needs to be in a hospital and they can’t get in for weeks. Well, you’re not going to terminate care, obviously. But also, now you’re treating a client who’s potentially not appropriate for outpatient. We’ve been I’ve been having a lot of very candid conversations with clients treatment plan contracts, which is going based on how you’re presenting, this is the course and plan of treatment that is recommended. These are the steps I want you to take. This is the timeline we’re both agreeing on. And if the treatment plan isn’t able to proceed as we’re discussing, then it’s not going to be a good fit for us to continue to work together. So I have lots of very candid conversations, I have contracts for safety. I have lots of case consultations, I have mandatory requests for clients to be seeing an dietitian how many times a week or a doctor how many times so that there is a sense that there are multiple eyes on the person. So we do a lot of conversations about that, just to kind of try to make sure that clients are getting the containment and the support and they need while also staying safe. And also working with the system that we’re kind of living in right now in the pandemic, which is not unfortunately a rapid, imperfect one.
Katie Vernoy 28:51
Well, on the other end of things, if someone’s fasting, or someone is restricting or purging or those kinds of things, I mean, those things are not going to change overnight. And I think people get fearful because if someone throws up twice a day, is that a medical risk? If they throw up once a week? Is that a medical risk if they’re fasting every other day? Or if they’re restricting down to a certain amount? Or? It seems hard to know, like, at what point do I need to ring these bells? At what point do I need to either try to seek inpatient or whatever it feels like there’s this nebulous area where some of it is like, intermittent fasting as a diet that’s going on right now. Right, you know, restriction and deep restriction has you know, I saw in a, this was many, many years ago, but restricting calories down below a certain point for long periods of time was shown to have health benefits or something like it was like it was it’s it’s stuff that doesn’t make sense. There’s also the whole medical model that’s giving us information that doesn’t align with this anti diet culture. And so I think for me, it’s It feels hard to sort out. When is this? I’m holding space and we’re talking about it. And when is it hey, I need to get this person to a doctor or say like, No, you have to change this, or else I’m terminating you.
Rachel Coleman 30:14
This is where the board would say, you’ve got a lot more wiggle room than you think. This is where the board would say like, Well, yeah, I mean, you’re not necessarily doing anything illegal by seeing someone who’s purging X amount of times. But as quickly, how can we do no harm? How can we support the client to getting better, and are they able to change and contain and shift this harmful behavior in our current therapeutic plan, I think the examples you just listed, absolutely warrant a higher level of care. That is something I would probably easily identify based on how you’re presenting based on your frequency of symptoms, I, you definitely need a high level of care. Now let’s talk about what the plan could be to get you there. And if it takes a few weeks, I’m here. And if it takes a little while to convince you, then let’s talk about Stages of Change. Let’s talk about pre contemplation. Let’s talk about all the other things that we can talk about and spend time exploring, while still holding a boundary of listen, I think that you need more support than I can offer you in order to get this, these things changed. And these things are scary. And medically, it’s not okay for your body. And so I can’t just sit here and be like, we’re gonna process how you feel about this. For weeks and weeks on end, we have to kind of hold that fine line. You know, it’s funny, you say that about like, when should you refer to the doctor? I mean, for me, that’s just kind of my standard, like, if you’re going to be seeing me outpatient and you have a diagnosable disorder, you will be in a team, I am not going to be the only provider. Makes sense.
Curt Widhalm 31:51
One of the big trends in our fields is the role of lived experience that a lot of clients are seeking out and kind of looking at the the ways that some of the therapist behaviors that you’re talking about earlier, can trigger clients, do you have any recommendations for people with lived experience as far as how to walk this line and being able to talk about their own perspectives of having received ED treatments in working with clients who are presenting with ED related behaviors.
Rachel Coleman 32:21
So what whether clients should share they’re in recovery,
Curt Widhalm 32:24
Whether a therapist, yeah should be talking about their own experiences in recovery.
Rachel Coleman 32:31
I mean, I do think that a lot of clients do feel better if a therapist is able to identify and reveal that they are recovered themselves, and they’ve been there. I don’t know if details are needed, I think it can be one of those things where it’s, you’re really what you’re really trying to validate is the client’s pain. You know, I can see your pain, I have some experience with my own pain, I will never feel yours, though yours is unique, yours is your own. But I know that this is a long process. And I know that things are hard. And I have empathy. And I validate your experience. I don’t know if therapists need to go into details about their own stuff. Because the nature of an even shorter is to be highly competitive, and to be comparing a lot and comparing, when you’re in an even shorter only makes you feel worse, it never makes you feel better. I think you definitely want to make sure you’re not triggering clients eating disorder brains to start doing extra, you know, comparison and calculation. But maybe a general sense of I validate and see your pain. And I also know that recovery is possible. Because a lot of times when a client’s struggling, they don’t think that there’s hope. It doesn’t feel like there’s a light at the end of the tunnel. And so if there’s things that the therapist can say that will make clients feel hopeful and know that recovery is possible. And I think those things are really therapeutically benefit official, but probably best to keep personal disclosures out of the therapy room.
Curt Widhalm 33:57
One last question is looking at the way that ED is taught. What would you add to curriculums to help people better be able to be prepared in working with this kind of a client population?
Rachel Coleman 34:13
That’s a great question. I think I think what’s missing is the complexities of how eating disorders present. I think we get there like little box DSM criteria. But we don’t really get the fact that every single eating disorder is as unique as the person. So no eating disorder is the same sitting in a room and being able to ask a lot of these questions that we’re kind of talking about, I think it’d be really beneficial for therapists to be educated on the various non stereotypical ways that you disorders present and all the great questions that people can ask. I do talk at grad schools a lot and when I do I bring my intake forms, and I pass out my intake forms for students to look at because one of the things I want to teach them is what questions to ask and what things to look for. And just kind of it basically gives them a better understanding of what you sores even look like on your couch, the various ones, the examples, and all just all the very detailed variety of how these these diagnoses can present so that they’re able to recognize it, because otherwise you just get the DSM criteria and the Hollywood movies, which are portraying anorexia in one way. And it’s just it’s not, it’s not sufficient enough.
Curt Widhalm 35:31
Where can people find out more about you and your practice?
Rachel Coleman 35:35
Sure. So my website is http://www.rachelcolemanceds.com. And that’s probably the best bet. Like I said, I suppose I dabbled social media. So you can kind of take some months off, and sometimes I’m like, Oh, I have some thoughts. But my Instagram is at Rachel Coleman MFT. And I have a Facebook page with my name as well.
Curt Widhalm 36:00
And we will include links to that in our show notes. You can find those at MTSGpodcast.com. And you can follow us on our social media come and join our Facebook groups, the modern therapist group and share with us your experiences of eating disorder, education, or lack thereof, and things that you would do to help better our fields when it comes to serving our clients. And until next time, I’m Curt Widhalm with Katie Vernoy and Rachel Coleman.
Katie Vernoy 36:31
Thanks again to our sponsor SuperBill.
Curt Widhalm 36:33
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Katie Vernoy 37:17
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