By Tracy Narins Welchoff, Ph.D
What are “Accommodation Behaviors”?
Accommodation behaviors involve participating in or supporting the Eating Disorder behaviors.
Examples of Family Accommodation
Accommodation behaviors interfere with learning new information:
Assisting a family member in avoiding anxiety (with the intention of being helpful to them) interferes with an opportunity to experience the anxiety, do nothing to “protect” themselves, and realize that the anxiety reduces on its own (this is called “habituation”).
Family accommodation behaviors can cause stress in the relationship:
Over time, it is easy for family members to develop resentment and frustration at having to make accommodations (such as buying special foods, changing who is “allowed” in the kitchen during cooking and eating, etc.). Using accommodations (which are often unreasonable) to “keep the peace” will backfire when the anxiety returns. It can stress the entire family system that is working hard (without benefit) to provide relief (often with the family’s inconvenience).
Family accommodation behavior can be motivated by the many reasons:
Accommodations are often motivated by guilt, anxiety, or difficulty tolerating the anxiety of the ED sufferer. Though intended to be helpful, they rarely provide comfort or protection but rather support the continuation of ED behaviors. It is understandable to want to accommodate because “at least they will eat”, but this actually reinforces the abnormal or symptomatic behaviors. Although it may seem to help in the short run, it typically fails to reduce symptoms in the long run (and in fact can strengthen the symptoms).
What does work?
What works is careful adherence to the Exposure Therapy protocol developed by the treatment team. Supported by a wealth of research, Exposure Therapy is the treatment of choice for Eating Disorder (and many other anxiety-based) behaviors. This involves gradual exposure to what is scary (i.e. eating a dessert, eating in front of other people), preventing the unhealthy response such as avoidance or purging), and teaching the individual that the feared outcome will not occur, or if it does, is really no big deal. Although hard to watch a loved one experiencing anxiety, rest assured that this technique is highly effective.
“Feel the Fear and Do It Anyway.”
By Maddie Welchoff, Nutrition Intern
During treatment, well-intentioned friends or family members often ask “Why does my loved one need to eat [Insert Food]?” The implication is that the food stated is somehow a bad (or unhealthy, or junk, or processed) food, or at least not a good (or healthy) one. This often comes from a place of compromise, of relief that the person is at least eating in a normalized way. But for treatment to be successful, you cannot compromise with the eating disorder.
A very practical reason is as follows. Once your loved one leaves treatment, they should (eventually) feel comfortable going out to parties or even friends’ houses to eat. But what if the only foods available at the place they go are “bad foods”? They may feel that they should not, that they cannot eat them. This inability to join others in eating could very easily lead someone in recovery to use symptoms to cope with the fact that their choice is “bad food” or no food. Leaving such a significant opening for symptom use in recovery is just asking for a relapse.
You may think “They can just bring something to eat!” but by separating themselves from others and eating different (“healthier/safer”) foods, they are still giving in to a disordered mindset. This is because they are following a food rule. Food rules are a very integral part of many eating disorders. Some eating disorders even start with “sensible” food rules that spiral out of control. So having rules about what foods you are and are not “allowed” to eat, even if the foods you are not “allowed” to eat are “unhealthy/bad” foods, these rules are eerily similar to those many people have in their disorder. This can lead individuals to spiral back into stricter and stricter rules, which can lead to symptom use and eventually relapse.
The last, and largest, problem with this mindset is that your loved one ends up basing their worth on what they eat. When they eat “good” foods they feel that they have been well behaved, virtuous, moral. But when they eat “bad” foods, they feel that they have been bad, disgusting, weak, or other negative characteristics. This is often subtle and not even something people are conscious of. But by basing self-worth and self-image on what is eaten, they are once again giving in to the disordered mindset that they are only as “good” as the foods they eat. Basing self-image on what you eat is a huge trigger to relapse for many people.
So why do they need to eat that? Simply put: to reinforce that all foods are okay, and no matter what they eat, it does not affect their value as a person.
By Tracy N. Welchoff, Ph.D.
Supporting your loved one through eating disorder recovery can be confusing, frustrating, and worrisome. In some instances, meals may become a battleground as family members try to beg, bribe, cajole, threaten, or scare the ED sufferer into completing a meal. It may be a silent, angry affair, full or arguing or tears, or empty seats as family members (including the ED sufferer) storm off or refuse to come to the table. For the patient, meals can feel agonizingly long and stressful, feelings which are compounded by being in the “spotlight” as the rest of the family watches to see what will happen. Other family members may resent the tension at the table, become too worried to eat, or talk about topics that are upsetting or “triggering” to the patient. Often, families give up on eating together.
If any of this sounds familiar, don’t despair. We are here to walk you through the process of returning some normalcy to the family meal. It may take some time, but with patience and willingness to try new ways of managing meals, improvement will come.
Although it is unrealistic to run your kitchen at home as we do in our therapeutic kitchen, understanding how we handle meals at NEDC can be a helpful place to start. First, the structure and consistency of meals are critical in containing anxiety and normalizing eating. When meals are predictable experiences, they contribute to a set of expectations in terms of mealtime behavior, food completion, and managing emotion at the table. Making sure that the atmosphere is supportive matters as well, perhaps even more so. Understanding that your loved one is not deliberately being difficult helps them feel less judged, hopefully countering the self-judgment that they are undoubtedly experiencing. In the NEDC kitchen, meals are at the same time every day, the table is set beforehand, and when food is served, everyone remains seated for the duration of the meal. All food and drink must be completed with no exceptions. There are no substitutions once food is served, no playing with food, and no using the bathroom during or immediately after meals. Meal plans are made in advance to prevent last-minute indecision or negotiating about what to eat.
In implementing supported meals at home, please consider the following:
Despite what you make think, it is not your job to “make” your loved one eat. Your job is to gently encourage (“try your best” or “try another bite”), support (“I know this is hard”), acknowledge (“I know this is hard” or “I’m sorry you are having a rough day”), and provide positive focus (“we will get through this”). You can never go wrong with making eye contact, giving a supportive smile, conveying an “I don’t mind this because you are SO worth it” attitude, and simply saying “I love you”. You do not need to know the “perfect” thing to say or feel responsible for the completion of the meal. Report to the treatment team what is and is not being eaten, and move forward from there.
This information may seem overwhelming, but with some practice, patience, and ongoing communication, long-term recovery is absolutely possible. No matter how worrisome, challenging, or endless this process may seem right now, the effort is worth it, so never, ever give up.
By Tracy Narins Welchoff, Ph.D.
Having someone you care about struggling with an eating disorder is understandably upsetting. It can also be confusing, leaving you feeling like everything you say or do is somehow “wrong”. Although this is certainly not the case, the constant, high level of anxiety that comes with an eating disorder can make for some tricky situations. Although it would be impossible to provide a complete list of ways to be supportive, here is a place to start.
By Tracy Welchoff, Ph.D.
Eating and substance abuse disorders are a common combination that we see too often in our work. The co-morbidity has been heavily researched, and the same evidence-based counseling practices- Cognitive-Behavioral Therapy, Dialectical Behavior Therapy, and Motivational Interviewing- have proven to help both disorders. One of the many commonalities between EDs and substance abuse disorders is how often they are misunderstood. We hear questions like “why can’t they just stop using?” just as others ask, “why can’t they just eat?” There are many reasons why these diagnoses often co-occur. Overlapping characteristics include high impulsivity, low self-esteem, history of trauma, tendency to isolate, and the desire to be outside of oneself and escape reality; consequences include poor physical health, depression, shame, and guilt. Individuals with either of or both of these diagnoses can experience stigma that may be greater than other mental health diagnoses due to the general perception of both disorders as “self-inflicted”. When attempting with a patient to compare their eating or substance abuse disorder to another disease like cancer or diabetes, I often hear the same response- “but this is my fault. I chose to [insert symptom here]. It was my decision.” Convincing them otherwise tends to be challenging, as individuals with these disorders are normally comfortable with self-blame and resistant to any suggestion to the contrary.
According to research done by National Institute on Drug Abuse (NIDA), 6 out of 10 substance abusers also meet criteria for another mental health disorder. This could be because drug abuse can cause mental illness, mental illness can lead to drug abuse, or drug abuse and mental illness are both caused by common risk factors, such as genetic vulnerabilities and environmental triggers. Drug abuse and eating disorders also trigger the same “reward centers” in the brain to keep the behaviors going. Endorphins are released as rapidly in a binge/purge cycle as in use of an opiate, and it takes time-usually weeks, months, or even years- without the unhealthy behavior for endorphins to be released normally again (as a result of another pleasurable behavior). This explains the depression and anxiety our patients may experience without symptoms and their complaints that no other coping skills produce the same calming result. No wonder it’s so difficult to give up symptoms! It also explains why our dually-diagnosed patients may relapse into substance abuse while recovering from their ED (or vice versa).
At Narins EDC, it’s often difficult for participants to talk about their substance use. In chemical dependency treatment program, it can be challenging to talk about eating disorder behavior. Ironically, even those suffering with these co-occurring disorders stigmatize other mental health disorders. Hopefully, providing education and understanding about the risk factors of both disorders and their co-occurrence can encourage the openness needed to address both head-on.
By Tracy Narins Welchoff, Ph.D.
Undoubtedly the most commonly asked question of friends and family members, it is understandable that loved ones want to know why their loved one is suffering from this scary, confusing, complicated illness. Is it the parents’ fault? (Nope.) Is it vanity or a desperate attempt at getting attention? (nope and nope.) Is it a choice? Is it a behavior problem? (Still nope.) In fact, there is no simple answer to this important question. Eating disorders are complex and affect people of all ages, ethnicities, socioeconomic groups, genders, and education levels. They impact loving, supportive well-functioning families as well as families with significant dysfunction. Eating disorders also occur in people of all shapes and sizes. External appearance should never be used as an indication of someone’s potential to develop an eating disorder, nor is it an indicator of its seriousness.
Risk factors involve a range of biological, psychological, and sociocultural issues. These factors may interact differently in different people, so two people with the same eating disorder can have very diverse perspectives, experiences, and symptoms. Although not an exclusive list, the following can be considered in trying to understand the myriad of contributory factors to the development and maintenance of an eating disorder.
Genetic factors work in combination with environmental, psychological, and other biological effects to increase risk. An individual’s genetic predisposition might influence how one responds to the environment as well as what environments an individual might seek out. Eating disorders are not a choice. They are serious psychiatric illnesses accompanied by a high medical risk. It is important to know, however, that eating disorders are treatable and do not automatically last a lifetime. Early, aggressive treatment is widely considered the best approach as this minimizes lasting physical problems as well as psychosocial and developmental disruption. Recovery is possible and always worth fighting for. Please reach out to the staff at Narins EDC if you have questions or concerns.
by Tracy Narins Welchoff, Ph.D.
A luxurious bubble bath, scented candles, soft music, a perfect cup of tea… sounds wonderful, doesn’t it? Although fabulous when you can engage in this kind of self-care, this is only the tip of the iceberg when it comes to treating yourself in ways that lead to a happier, healthier, more productive and meaningful life. Although the above scenario (or your personal version of relaxing) is where the mind often goes when considering self-care, there are actually many different, and equally important, ways to take control of your well-being. When life is overwhelming, it can help tremendously to slow down and ask yourself what kind of self-care you have been neglecting. Here is a quick rundown of the different categories of self-care that you might consider:
But it feels so selfish!
Getting past this feeling is so important… allowing yourself to regularly engage in activities that promote wellness can boost your mood, support good health, enhance productivity, and put you in the best possible position to contribute to the wellness of others. You are worth it!
by Tracy Narins Welchoff, Ph.D.
Family Based Therapy (FBT) is an approach to treating eating disorders that recognizes the powerful influence that families can have on their loved-one’s recovery. Thankfully, the outdated notion that parents cause eating disorders no longer dominates the treatment community. Rather, the family is appreciated as a tremendous support and agent of change. Although FBT is typically used with children and adolescents, the principles of FBT can be adapted to benefit adults as well. Family Based Therapy is based on the following principles:
By Hannah Bock, Recovery Warrior and fabulous guest blogger
I was sitting in my dietitian’s office, listening to her telling me for the thousandth (at least) time that something had to change. I’d been in active recovery for about 11 years, and in that time I could reach a point of stability in recovery, but I could never actually call myself “Recovered”. What was I missing? What was I doing wrong?
The realization hit me like a ton of bricks: I had to cut out exercise.
I’d been struggling with compulsive exercise for years, almost the entire duration of my illness. During that time, I would eat any meal plan that I was given, do all of the journaling and self-care prescribed to me, and participate actively in individual and group therapy sessions. The one thing that I was unwilling to let go of? Exercise.
I always had a reason to continue to hit the gym. Despite repeated suggestions from my treatment team to quit, I couldn’t stop. Working out was my drug of choice. It made me feel great about myself, it was a way for me to relieve stress, and I loved my identity as “The Healthy Girl”. I never felt like I was going to the gym too much, and I never felt like exercise was negatively impacting my life. After all, how could something that society says is so good for you possibly be bad for me?
First, I had to understand and accept the difference between over exercise and compulsive exercise. According to my justification, I wasn’t spending hours and hours every day at the gym, so I was fine, right? Wrong. Although the time I was spending exercising wasn’t considered extreme, it was still disrupting my daily life. Accept an invitation to go out with co-workers in the evening? Sorry, I have to work out. Birthday dinner with my fiancé? Have to make sure I get my run in that morning. Spend the day at my friend’s house because she just had a baby and can’t really go anywhere? Maybe for a while, but then I have to make sure I can get to my 4:00 class at the gym.
My compulsive workout schedule didn’t stop at dictating my social calendar. It constructed my food rules, too. What I consumed in a day depended completely on whether or not I had “earned” it at the gym. My workouts even dictated which outfits I was allowed to wear in a day. I did not trust my body to tell me that it was hungry or full. I did not trust that my body was fine in whichever outfit I chose that day. Exercise was the control that I thought I needed over my body.
After I made the realization that I was indeed exercising compulsively, I did something that was terrifying and seemingly impossible. I made the decision to try something that I had never tried in recovery before. With the support of my therapist, dietician, and fiancé, I surrendered all of my sneakers and my gym tag. I gave up my workouts indefinitely.
The First Week
The first week was loud. The eating disorder voice in my head was relentless. Strains of “Why would you do this? You’re going to get so fat! You’re going to get so out of shape! You’re not even going to be able to walk up a flight of stairs! What are people going to think? The healthy girl, the runner? Can you even call yourself those things now that you’ve just given up?” were constantly scrolling through my head, making it very difficult to focus on anything else. I am incredibly fortunate to have a strong support system. As I voiced my thoughts, I always had someone there to help me debunk my ED’s hurtful accusations and reshape my thoughts. The first week was by far the hardest, but with help from my amazing supports (and a lot of crying, arguing, and attempted bargaining), I got through it.
One Month In
After about 4 weeks of discovering new ways to cope with stress (some of which worked, some of which did not), I had a pivotal light bulb moment: Nothing bad had happened to me. I still fit in my clothes. I still got up and down stairs just fine. No one made comments about my break from the gym. I had an appointment with my dietician, and although I was expecting tremendous weight gain, she assured me that was not the case and that my weight was the same. The same! It was in that moment that I had my third major realization: Maybe I could trust my body.
98 Days In
After the first month, I started challenging myself in ways that I never thought I would. I started listening to my body. At first, this was very difficult and confusing. If I got hungry, my first reaction was always, “I didn’t do anything today, so how could I possibly be hungry?”. After repeating my ED’s thoughts out loud, I would remind myself that all humans need to eat to survive, and hunger cues are your body’s way of signaling that you need food, just like being thirsty means that you need a drink and being cold means to put on a sweater. They’re all signals that your body sends, and guilt should not be a reaction to hunger (or thirst or cold). I started to honor my hunger with foods that would satiate and satisfy me. I learned in that time that I really like Indian food, that I feel way better when I put dressing on my salads, and that cottage cheese doesn’t really agree with me. I went out with my friends and tried new restaurants. I spent more time with my fiancé because I didn’t have to rush to the gym after work or first thing on a Saturday morning. In short, I felt like I was connecting with people I loved and like I was living the life I truly wanted to be living.
The 99th Day
On the 99th day, it was very nice outside. I drove to work with the windows down, looking at the woods on the side of the road and remembering when I used to go exploring in the woods when I was younger. I wanted to be outside in nature. I happened to have an appointment with my dietitian that day, and I told her that I really thought I was ready to add some movement back into my life. I wanted to connect with nature and feel my body move. I wanted to appreciate what my body could do instead of forcing it to do something it couldn’t. I wanted to honor my limitations (as it turns out, all humans have them) and listen to my body when it asked for exercise. I didn’t want exercise to be a scary thing anymore. Just like I had to learn to listen to my body’s hunger cues, I had to learn to listen to my movement cues, too. My dietitian agreed, and the next day I went on the shortest but most enjoyable jog of my life.
Today I’m still working on my relationship with food and exercise, but it has come a very long way. Fear is not a word I use to associate with going out to a restaurant or skipping a workout. Guilt doesn’t bubble up in me when my friend brags about how far she ran yesterday and I brag about how far I got in my current Netflix obsession. Hunger isn’t a good thing or a bad thing, it just is. Some days I want to move a lot and some days I don’t want to move at all. Some days I’m really hungry and some days, not so much. I’ve learned to hear what my body needs and respond appropriately.
Warriors, this has not been an easy road. I am extremely fortunate to have amazing supports and an outstanding team help me through the tough times. Although I am not fully recovered (and I DO believe in full recovery), I am the most recovered and the happiest I have ever been. Giving up exercise to gain back my life is the best thing that I have ever done for my recovery. It was scary, Warriors, but if you have an inkling of suspicion that giving up exercise might be what you need, you won’t regret it. Remember, nothing bad will happen to you.
By Tracy Narins Welchoff, Ph.D.
It is no secret that our society is obsessed with dieting an losing weight. Magazine covers, billboards, television and radio commercials, and fitness centers popping up on every corner remind us almost constantly that we need to lose weight, even if we don’t. This is not to deny that there is an obesity epidemic that must be addressed. However, dieting is not the answer, and here’s why:
“So what do I do if I am overweight?”