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Body Dysmorphia

A Therapist’s Role in Eating Disorders

By Krupa Shanware

In this episode, Taarika youth ambassadors Krupa and Anisha interview Dr. Nan Shaw, a therapist, about family-based therapy and its uses in relation to eating disorders.

Taarika Foundation(TF) Krupa: Welcome back to another episode of Mindful, Beautiful, and Thriving. Once again, I’m Krupa,

TF Anisha: And I’m Anisha! Today we’ll be continuing our podcast series on Body Dysmorphia and Eating Disorders with an interview with a therapist who specializes in eating disorders and family based therapy. 

TF Krupa: Today’s guest is Nan Shaw. Nan, thank you so much for speaking with us today!

Nan Shaw: Me too. Thank you!

TF Anisha: So first off,

Would you tell us about what kind of therapy you provide for youth, specifically, with an eating disorder? 

Nan Shaw: Yeah. So primarily when working with teens with an eating disorder I offer family therapy, and specifically family-based therapy(called FBT), which is a very specific kind of family therapy that is designed for adolescents with eating disorders. It’s an outpatient therapy that takes 6-12 months to complete. Sometimes it can take longer, sometimes less time, but that’s basically generally how it goes. And another part of that and how I work is also working with teens. I work with doctors, dieticians, and the family therapist, and as part of the family therapy I meet with the teen and the parents together. And sometimes the siblings too. And then if there are situations where a family can’t be involved, let’s say a college student that lives far away from their family, I sometimes also work with the teen/adolescent only, that’s called adolescent-focused therapy.

TF Krupa: That’s super interesting, I didn’t actually know you work with the family as well as the child. So [since] you specialize in family-based therapy,

Could you elaborate a little bit about what working with a patient’s whole family is like, and family involvement is important?

Nan Shaw: The working with the whole family I personally think is wonderful, I came and do this work as a family therapist anyway, and I particularly like that because really the whole family is involved in the illness, I think it’s important to involve the whole family in the recovery, and everyone is sort of in on it and everyone in the family also deserves to have the education, the support, the tools to help the teen with the eating disorder get better. But the primary focus really is getting the teen better. Family involvement is important because at its core an eating disorder is considered an illness that is keeping the teen from eating enough to survive or feeling out of control maybe with eating too much or purging and it’s the nature of the illness that the teen can’t change this by themselves let’s say. So who better to help than the parents. And also I just want to say when I say parents I also mean caregivers, maybe whoever is caring for the youth whether it’s a parent or someone also in charge. And the other reason I think it’s important to include the family is that by the time an eating disorder has been identified in a teen, they’ve been struggling by themselves for quite a while, and it’s scary and exhausting. So I think of it as sort of when they’re getting the family involved, so like the cavalry has arrived and they no longer have to do it but themselves.

TF Anisha: Right. I’d just like to say that that’s really eye-opening to me and something I didn’t know before. So we actually previously talked with a teenager who did struggle with an eating disorder and they talked about how it helped them open up to their parents a lot more. So I think on that topic,

Would you be able to talk about just what common challenges you come across when you work with teenagers and teenagers’ families?

Nan Shaw: So that’s a great question actually. Probably the first one I think of is that for the teen, even a teen that wants help, this type of treatment, family-based treatment of really any eating disorder treatment, can initially feel like things are being taken away. Whether it’s the diet they’re interested in or an exercise they want to do, that suddenly parents and other people such as myself are all involved in that. And it can feel, particularly I think to teens who are more independent and doing more by themselves to suddenly have professionals all in their business and parents all in their business, can feel both insulting and threatening and of course that’s not the goal. And because the illness by definition creates a situation where a teen isn’t eating enough or is purging too much and can’t intervene, we have to do that. But it can feel like something’s being taken away.

Another thing I think teens often [find] challenging with eating disorder recovery is if they’re dealing with anorexia and have to gain weight, that’s a hard thing. I mean we live in a culture where losing weight is always honored, and we have no idea when someone’s losing weight, and gaining weight is always judged or at least it feels that way. And so hearing from a teen in and saying “Guess what you have to gain weight,” that can be a hard thing to sit with comfortably.

Two other challenges I think of, another is that there’s sort of a belief in this treatment that all life stops until you get better and that is to prioritize recovery over everything else. And so teens that are heavily invested in their academics, studying for the SAT, or loving their soccer team, suddenly everything is “Wait, hold up, you can’t do this, you’re gonna have to leave school early” or you know “Soccer’s on hold.” That can be really hard and scary. In truth we have to “All life stops” until you get better. And then I think the last challenge for teens is they can feel pretty ashamed of what’s going on and isolated, maybe not talking to their friends, not wanting to go out and have pizza with their friends because they’re having a hard time having pizza, feeling really out of step with their peers.

TF Krupa: Yeah that was perfect. I didn’t really know any of that before, and I’m glad that we could talk about this because I know a lot of teenagers, they have these kind of like isolation issues and things about missing out on their teen years in general. And I feel like having an eating disorder would amplify that so much through recovery. I know everyone’s experience must be different, but just a follow-up question:

What advice would you give to youth dealing with an eating disorder, or for their parents?

Nan Shaw: So, let’s start with the youth with the eating disorder. I’d start with hope, that people get better, that there’s treatments out there that have been shown to work. FBT has been found to be quite successful, it’s the most successful treatment, considered really the first one. So, not to give up hope, and then [they’re] not in this alone. I would remind them that things that are being taken away or ways that the therapists or the parents are intervening are just for now, that’s sort of the hallmark of family-based treatment that we often end every sentence with, and that’s just for now. Because that’s true, [as] soon as a teen is feeling better, weight restored, eating more appropriately, we want to give all these things back. That’s the goal of treatment. So “for now” is a really important concept.

I think I would also advise “Tell somebody.” It’s an illness of secrecy, an eating disorder thrives in secrecy, and so the more open and honest a teen can be with those around them where there’s friends, parents, teachers, the better [the] chance for recovery.

And an eating disorder can’t live where there’s openness and honesty,

Dr. Nan Shaw

so I would say tell somebody, and then recognizing that recovery is hard, treatment is not all that comfortable, and that it may be hard and it may feel a little worse before it gets better but it absolutely gets better. So I would also want to say “Hey, this gets better. Hang in there.”

So for parents, I would have different advice. Some of it is similar, things like hope and “You’re not alone,” and “This is just for now,” are all important concepts for the parents, who can feel kind of bad and weird to suddenly be making sure you’re home for dinner, things like that. So “For now” is really important for the parents to know as well.

The other thing I say to parents is often by the time an eating disorder is recognized, it’s really just the tip of the iceberg, that what you can see above the water is just a little bit. You kind of go, “Huh, my kid’s struggling a little bit,” but often what’s beneath that and once treatment starts there’s a whole bunch of stuff going on underneath and that the eating disorder might be much more powerful on the teen than parents ever realized. So I’d like to prepare the parents for that, that maybe what you’re seeing is just the tip of the iceberg, and because of that, parents [who] do the quicker success to recovery goes to parents who basically kind of drop everything at the start and really focus. So they may have to take off from their work to really focus. So it’s, say, all hands on deck, giving all you got as soon as you find out about it. And you can’t overreact. I often tell parents, because parents say “Well I don’t wanna overreact, do I really have to keep her from camp,” and I might say “Well you can’t overreact, because you’re trying to save your kid’s life.” So maybe she could have gone to camp or he could have gone to camp, but why not keep them safe if you need it?

And the other thing, it’s really important for parents, is this idea of prioritizing their child to get better versus feel better. Getting better means hard stuff like eating a meal or completing a meal you don’t want to, or gaining weight if you don’t want to, or not being able to use the bathroom after a meal if you wanted to. And both for teens but also for parents, it doesn’t feel good if your kid is uncomfortable. You don’t want them uncomfortable. And yet recovery is in the analogy we often use, you may have heard this before, is imagine – and I’ve worked with parents before who use this for children children who’ve had cancer for example, and chemotherapy tends to be pretty uncomfortable, and yet if a child was struggling to go do that, the parents don’t go “Ah you can skip it today.” They will say, “I am so sorry,” and “I know this is hard,” and “I’m with you every step of the way, we’re going to get through this.” Feeling better would be to skip it right, but getting better would be to go but doing it lovingly. So that would be what I would say to the parents.

TF Anisha: Thank you for all of the advice you just gave, I think it was really helpful and I really hope that it does resonate with anybody in the audience. And so, kind of I think this was a perfect segway for the next question, because on the topic of people silently struggling with eating disorders, I know that me and people and in my community and both Krupa and I, we’ve seen people maybe start on that path to maybe a really difficult eating disorder or any sort of form of feeling body dysmorphia. And it’s an uncomfortable decision to have with a friend, so just

If you could give us any advice on how to make that better for everyone to kind of lovingly approach that sort of topic with a friend, that would be great.

Nan Shaw: That is a great question. And I guess the first thing I’d want to say is there’s no right answer. So feel free to do what kind of feels right. I guess I’d answer that two ways. If somebody that either – sibling or a friend – is not in treatment or you don’t know if they’re in treatment, I would suggest one, making it talkable. If not with a friend, you know you don’t feel comfortable talking with a friend, maybe just someone else. So you as the observer that’s worried can also go to another adult, teacher, school counselor, parent, your own parent, just say “I’m worried.” So, you could approach the friend or approach somebody else so you can get some help because being worried about a friend also creates its own anxiety. 

If you want to talk to the friend, and again there’s no right answer here […] I like to recommend what I call

“Share the Dilemma.”

Dr. Nan Shaw

So, your question is even a dilemma. “What do I do, I care about this person I want to say something, is it my business? Will I hurt their feelings?” It’s a dilemma. So a great way of approaching dilemmas from my perspective is you share. And you go to this friend [and say] “I have a dilemma. I care about you, I’m worried about something, and I might be completely off and I also don’t want to upset you or make you mad. But I wanna ask you if you’re okay.” […] So you share the dilemma, and most of the time that goes really well because you’re not coming at it “I know and I know exactly what needs to happen and I’m worried.” But you’re like “I don’t know what to do here but I know I care about you and I’m worried and this is what I’m seeing.” So that’s […] if somebody’s not in treatment and you’re worried they’re not getting help.

If somebody is in treatment, and you’re worried about them, for whatever reason, one of the things we say in family-based treatment, the friends and siblings, in particular, the role of a friend and a sibling is just to do that, a friend and the sibling. So you say “Hey let’s go see a movie” or play a game or if you see them struggling with a meal, distract. Talk about the most recent episode of Grey’s Anatomy or something. You just play the role of  a friend and a sibling in a distracting way, it’s not your job to make them feel better or feel responsible for their recovery, to just be a friend or a sibling.

And the other really cool thing friends and siblings can do is practice what a lot of recovery is, which has to do with body compassion, body acceptance. So you yourself don’t get involved, even if you want to, but you just don’t get involved in conversations about the latest fad diet or your own negative body comments, if you’re feeling that way, or any kind of judgment about body, […] size. And it could be good for the friend or sibling to also not engage in that, it’s usually not really very helpful. It doesn’t help our self esteem to bash our own bodies so it can be a very powerful difference just to not engage or if a friend says “Hey do you know how many calories are in what you’re eating?” you go “You know what I really just don’t care,” even if you do care.

TF Krupa: Thanks so much for that, I know it’s definitely going to be helpful for our listeners, and as Anisha said, both of us have seen people kind of start to go on that negative trend and I know that it will also helpful for us if it ever escalates for them. Thanks again for joining us on this episode of our series on eating disorders and with that comes the end of this interview. See you guys next week!

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