When Your Teen Has an Eating Disorder

You're listening to Burnt Toast. I'm Virginia Sole-Smith. Today my conversation is with Dr. Lauren Muhlheim.

Lauren is a psychologist, a fellow of the Academy for Eating Disorders, a certified eating disorder specialist and approved consultant for the International Association of Eating Disorder Professionals. She's also a Certified Body Trust Provider and directs Eating Disorder Therapy LA, a group practice in Los Angeles. Lauren is the author of When Your Teen Has an Eating Disorder and a co-author of the brand new The Weight-Inclusive CBT Workbook for Eating Disorders.

Lauren joined me to chat about how she and her colleagues have been working to make eating disorder treatment less fatphobic, because, yes, that really needed to happen. We also get into why it's feeling harder than ever to treat eating disorders, or live with one, in this era of RFK, Jr., MAHA and GLP-1s.

Plus what to do if your child is hiding food, lying or otherwise showing signs of developing an eating disorder. When do you intervene? And how do you do so in the most supportive way possible?

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Episode 231 Transcript

Virginia

I am really delighted. We have been, I guess I would say, colleagues in this space, or comrades in this space, for a long time.

Lauren

Comrades, for sure. 

Virginia

I've interviewed you for articles over the years. We're both in the fat activism world in various ways. You're someone I learn so much from. I'm very excited to have you here today. We are going to talk about your new workbook that comes out this month, called The Weight-Inclusive CBT Workbook for Eating Disorders. Do you want to give us a little background on how this workbook came to be? Then we're going to dive into my list of questions.

Lauren

I should introduce CBT for eating disorders. CBT stands for cognitive behavioral therapy for eating disorders, which is one of the leading treatments. I was trained in it back in the 1990s by one of the two main researchers who's credited with developing the treatment. Cognitive behavioral therapy looks at what's maintaining a problem in the present. It looks at the relationship between thoughts, behaviors and feelings, and helps to sort out ways to solve problematic behaviors related to eating. 

Fast forward to present day, we've learned a lot more about eating disorders than back in the '90s when I was trained in the model. When I was trained, it was very weight-centric, focused on primarily low weight and "normal weight." You know, thin-ish white women, and that's who was largely studied. 

But now we know so much more - that eating disorders affect all people, all genders, all ethnicities and all body sizes. As I've evolved as a clinician over the last 20 years, I've really become influenced by the weight inclusive movement, Health At Every Size and listening to people with lived experience who have experienced harm from traditional weight-centric treatments. 

So I have evolved. And in my mind I had modified what I was doing, and when I went back to look at the manuals, I was horrified to remember what was still in there that was really weight-centric. This has been a passion project for the last eight years. I've collaborated and talked to different people about it. I ultimately teamed up with two colleagues who were as passionate as I am, and we came up with the idea of modifying CBT to be weight inclusive.

We coined CBTWI to be weight inclusive, and we took the 30 year old manuals and updated them to be relevant to today and to speak to people in all size bodies. A lot of people come to us in bigger bodies and the old manuals were so harmful. You know, focusing on about being the right weight and other elements that were just not conducive to people in larger bodies when they go through this work.

Virginia

Can you give a specific example? For folks who've never been in eating disorder treatment, or just don't know the world well, it's like, 'What do you mean eating disorder treatments are not weight inclusive? Isn't that where you go to feel better about your body?' Give an example of what CBT used to do that was harmful, and how you've updated it.

Lauren

When I was trained in CBT, I always thought it was a non-diet approach, because the focus is on regular eating and including all foods. So the center of the model is still good. But some of the fatphobic elements that were in the original treatment were - one was this insistence on regular weekly weighing and the client knowing their weight. And that if the therapist refused to weigh the client weekly, it was the therapist's own anxiety and avoidance of tolerating the client's distress over being weighed. But if you're in a bigger body, being weighed is more than just exposure. It can be traumatic. 

Virginia

Yeah. 

Lauren

We don't need to put people through that, where every week they see their weight. So that's one of the first things that we eliminated. 

The other thing, there's behavioral experiments with a focus on challenging what they call the broken cognition. The broken cognition is this belief, and again, this was developed on primarily thin, white women who had the belief that if 'I eat a cupcake, I'll gain five pounds.' The behavioral experiment was to have them eat a cupcake, weigh them before and weigh them the following week, and prove that they didn't gain five pounds, but that's also hugely fatphobic. Because you're trying to prove to people that it's all in their heads, that weight stigma is not a thing.

Virginia

Well, and you're saying, 'Look, the scary, terrible thing didn't happen.'

Lauren

Which reinforces that that's the scariest thing.

Virginia

Even what you're saying, weighing folks in bigger bodies can be traumatic, not because inherently it's bad to be in a bigger body, but because if you're in a bigger body and you've been weighed in medical settings, you've had that number weaponized against you for so long. That's the trauma you're alluding to. 

Lauren

Yes, exactly.

Virginia

I see, so it was a lot of methodology around weight numbers meant to reassure thin women that 'Don't worry, you won't get fat.'

Lauren

Exactly.

Virginia

Which really leaves out any fat person with an eating disorder, and doesn't really do the thin women any favors either.

Lauren

Right. Because it just reinforces this fear that weight gain is the worst thing that could happen to somebody.

Virginia

That's fascinating. It sounds like a lot of very much needed updates and a really terrific resource for folks. I saw in the back of the workbook under Resources, you listed Burnt Toast as one of the newsletters with an online community dialogue. It means a lot to have us spotlighted in this way. We do work hard to have our chat rooms and safe spaces in the comment section for folks coming for support. You also listed a lot of folks that we love and look to as leaders in this space: Christy Harrison, Ragen Chastain, Rachel Milner, Sabrina Strings, Bree Campos, Chrissy King, etc. How do you think about the importance of community in the work you do with your clients as you've been reframing CBT in this way?

Lauren

We are big fans of yours and all the people you've named, and it was really important to us because here we are, three white women with privilege doing the updating of CBT and we wanted to take it further. 

It was really important to us that we learned from people with more marginalized identities. We negotiated with our editor to have sensitivity readers and we had people advising us on some of the things that we might not have been as aware of, like food insecurity, gender considerations, and the experience of people in larger bodies. As references, we tried to include some of the thought leaders that we've really learned from. 

Community is super important in this work because we're asking people to go against the grain of society. Many of the people that come to us for help with eating disorders are people in larger bodies who have been told by medical doctors and people in their lives to lose weight. And then they come to us and we say, 'Well, you're not eating enough.' And they think we're kind of crazy to say that. 

It really helps when you're asking people to do this work, which is so hard, to have other people in their lives who are supporting this. Many people don't have people in their personal lives who are anti-diet. Where do you find those people? A lot of it is online and in podcasts. I always tell people it helps, even if it's you and me and the person listening to the podcast. They're hearing the interviewer and the guest and there's two other people who are in this world with you. 

Virginia

That's right.

Lauren

It helps a lot. And I do think that is the missing piece for people in bigger bodies who experience disordered eating - they don't have the support.

Virginia

Especially right now. We're in a really dark cultural moment. You know, just like a swirling vortex of badness in a lot of ways. So it feels even harder, because what the federal government is telling us, what we're seeing in the news, etc, etc, is also running counter to what will actually promote healing. 

To that end, I'd love if we could talk a little bit about how you're thinking about your work in this dark time. We just had RFK’s latest USDA dietary guidelines come out.

Lauren, how are you feeling about the new food pyramid?

Lauren

Sadly, I feel like I am not going to be able to retire anytime soon. The culture just propagates and perpetuates disordered eating in so many ways. Obviously eating is so much more individualized than just following a guideline, but what I can say is that I have never seen a person with binge eating who was not restricting their carbs. 

Virginia

That’s really interesting.

Lauren

Carbs are basically the building blocks of what we eat, and they should be. A lot of the people who complain of what has now been popularized as the term "food noise," are not eating enough, and especially not eating enough carbs or starches. I expect that we'll see many more people coming in saying, 'I'm preoccupied with thoughts of food,' or 'I'm bingeing,' or 'I'm emotionally eating.' In our work, and what our workbook focuses on, is 'Are you eating enough regularly throughout the day? Are you including the various food groups? Are you eating enough starches and fats?' That's the mainstay of recovering from an eating disorder.

Virginia

Feeding your brain.

Lauren

Your brain needs glucose to think logically.

Virginia

Yeah, and not just at the tiny bottom point of the pyramid, but throughout the day. This is something I've learned from you that I want to make sure we say really clearly, because I think it's something people know but lose track of in their own work on these issues. Often folks come to you and say, 'I binge eat. I'm out of control with food.' When you start working with them your take is quite different.

Lauren

Right. All the eating disorders are really driven by restriction or not eating enough, and it's true that most people come to us and think they're eating too much. They're complaining about emotional eating or binge eating. 

As a cognitive behavioral therapist, one of the things that CBT therapists do is ask people to keep records. Early on I was taught to have people record what they're eating, and that really offers an insight into what's going on. In my group practice, we do a lot of training of more junior clinicians, including graduate students. It's really exciting to me when I have a graduate student who's been with me for a couple months, and I say, "Well, what do you think the diagnosis is?" And they'll say to me, "Well, I'm waiting to see the food records because the person's complaining that they're eating too much." But they know from having been through this a few times, that when you see what someone's eating, you see a lot of restriction, a lot of skipped meals, a lot of very sparse meals. 

People really do think they're eating so much because the culture is so focused on eating these very low intakes, and that's been kind of normalized on social media by wellness culture. People are really shocked when we tell them that they need to eat more, and that is the biggest part of it. Regular eating is kind of the antidote to all disordered eating. In our workbook, we're always like, 'Are you sure you're eating enough?' And I don't want to reinforce dieting by teaching someone strategies to prevent binge eating when they're not eating enough because I'm not going to be successful at that. Because that's the hunger drive and that's what keeps us alive. People may have short term strategies that work, but I definitely don't work on stopping the binge eating or the emotional eating until someone is really eating enough.

Virginia

Eating enough to support the idea that you would eat less at this one point in the day.

Lauren

And then most often, a lot of the binge eating and emotional eating decreases once people start to eat more regularly at meals and snacks. The food noise goes down.

Virginia

Let's talk about food noise. The rise of GLP-1s has really popularized that concept, but also, I would say, as you noted, misdefined it in many situations. How is all of that discourse impacting your work with your clients right now?

Lauren

It's definitely impacting us. We are seeing a lot of people coming in on GLP-1s, or contemplating GLP-1s. We always need to distinguish people who are on GLP-1s for medical conditions versus people on them solely for weight loss. 

One of the problems with being on them for weight loss is that they're on higher dosages, and that's where you get more side effects. We do get some people who come in complaining of binge eating or emotional eating, and then they're on a GLP-1 and they suddenly have no appetite. It's harder to get them to eat enough throughout the day.

Virginia

Right. If you're trying to go back and say, 'Wait, let's look at where you're restricting,' and now they can't access any appetite to eat.

Lauren

Or they're nauseous and throwing up. 

Virginia

Oh, God.

Lauren

We have been successful in a number of cases in helping our clients advocate for their doctors to actually lower their doses. Sometimes that helps, but there's a lot of nuance, right? I think we don't know enough about the full impact of these medications. Might there be some benefit for people with eating disorders in certain circumstances? Maybe. But it's a scary thing, and it definitely makes our work harder when we're focused on trying to get people to eat regularly throughout the day.

Virginia

That concept's been getting a lot of media attention, GLP-1s as an eating disorder treatment. But it sounds like you have major reservations about that idea.

Lauren

Because it does the opposite of the work we're trying to get people to do. Cognitive behavioral therapy is the best validated treatment. It was developed in the '90s and there's a lot of research to support it. The model is regular eating, including all foods, not being restrictive. And symptoms typically get better. We know that with weight loss, most people don't keep weight off long term.

Virginia

Right, and most people aren't able to stay on these drugs long term is also what we're seeing in a lot of research now.

Lauren

We do see some people who have been on GLP-1s and then they go off them and their weight is increasing and maybe the binge eating is coming back and starting again. It's a bit of a quick fix. That doesn't solve the problem.

Virginia

It's just rooted in that old thinking of binge eaters must eat too much, take away their appetite, solve binge eating, as opposed to what you've been steadily making the case for. And all the evidence is showing binge eaters are responding to restriction. And so a drug that encourages more restriction, how would that long term solve binge eating? 

I would love to also talk a little bit about managing eating disorders and disordered eating in kids. You specialize in teenagers. Whenever I have a reader or a friend, as I now parent a middle schooler, reach out with concerns. I'm always like, 'Check out. Dr. Mulheim's work. This is your first stop.'

You're a big proponent of Family Based Treatment, FBT, for adolescent eating disorders. On your website you wrote, "I do not believe that parents cause eating disorders, but I know they can be an important part of the solution. Hence, I'm an advocate for the inclusion of parents in the treatment of their children."

Let's talk a little bit about how parents can help. What behaviors and symptoms do you take seriously? How do you be part of that solution?

Lauren

The first thing is that eating disorders in children and teens is harder to spot than you think. My advice to parents is, if you have concerns, definitely check them out. Some of the signs we see are stopping eating certain foods, eliminating dessert or not eating meals and saying they've already eaten. We may not see weight loss in in a child or a teen. They may just fail to gain, because remember, they're supposed to be gaining over time. Sometimes they're growing and they're not gaining, and that's the equivalent to weight loss in an adult. 

We also see things like social withdrawal. What looks like depression, poor sleep, or loss of interest in activities. It can look like depression or anxiety. Or complaints of stomach aches. A lot of parents go down the gastrointestinal route, trying to figure out what's going on. It can be very confusing. Family based treatment is a wonderful evidence based treatment. It was developed at Stanford and it's a manualized treatment that basically allows teens to recover in the home. Because traditionally, teens were pulled out of the home. Parents were blamed. There was this saying about how it was always the mother's fault.

Virginia

Of course. Clearly.

Lauren

Clearly following on the trend of the schizophrenogenic mother, the autistic mother.

Virginia

We cause autism. We cause eating disorders. 

Lauren

That has really perpetuated. I still meet people who say it must be the parents. I try to remember we're all in this culture and parents are doing their best. Parents are getting diet messages from all these other health professionals in our culture. I try to remember that they become the messengers of the cultural message. There is often dieting in the home, but does that cause eating disorders in itself? No. And we see that because not all siblings develop an eating disorder. A lot of parents diet and their kids don't develop eating disorders. We have to give parents a chance. The great thing about FBT is it's done through family meals and normalizing eating all foods. It's a great chance for families to come together. 

I find it very powerful when the parents are unlearning their diet culture with their teens. They're able to do that. Sometimes it's a little bit of a hard wake up call, but most parents can get on board pretty quickly. It's really powerful when you see a whole family change the way they've been eating. It gives the parents a chance to learn the information. Whereas if the teen goes off to residential, the family doesn't come along and then the teen goes back into that home, so it's challenging. It's a lot of work for parents because they become the treatment team. 

Virginia

It is a lot of sitting at the table with a kid who doesn't want to eat, which, any parent, regardless of whether they've managed an eating disorder, can tell you that's a nightmare. That's really hard to do and often it can feel counter to some of the other messages we get. If you're looking at the Ellen Satter model of feeding kids, it will be very much not forcing kids to take bites, and in FBT, when you have a kid refeeding after a lot of restriction, you do have to require them to eat. And that feels really strange. 

Some of the interviews I've done with families who've done this, it is so moving to hear the parents work through their own stuff and come together in a different way to support the child. It's pretty transformative.

For parents who are noticing some of the early symptoms, like hiding food, or kids may be lying about what they're eating, how do you recommend parents manage things in those stages? Like, okay, I'm keeping an eye. I'm probably going to talk to the pediatrician. Probably going to, you know, do I need to level this up? And also, how do I react in the moment to some of this stuff?

Lauren

With as much compassion as they can, and in a non-shaming way. If you think that you know your kids are lying about what they're eating or hiding food, we really want to just encourage them to eat more with you. Which, again, this comes back to all eating disorders require people to eat more. If someone's hiding food, maybe they're not getting enough at meals. If someone is refusing to eat meals, they're not getting enough at meals. It's a good chance for parents to be more watchful, to try to make sure that meals are eaten and that teens and children have access to a variety of foods. That they're getting their nutritional needs met. 

A lot of parents, again, because the cultural messaging is so intense, think people should be eating less. If you've taken care of a growing teen, you see how much they need.

Virginia

How much your grocery bill has increased.

Lauren

Parents may not be aware that their teens are supposed to be going through growth spurts. I do some trainings with Rebecca Peebles, who's an amazing pediatrician, and she emphasizes how teens are supposed to gain about 50 pounds as they go through puberty. Where are you going to get that weight if you're not eating enough. The growth pattern for a lot of kids is to grow out before they grow up. There's supposed to be this weight gain. We observe teens who are starting to gain weight to fuel this growth, and then someone panics, whether it's the pediatrician or a parent or the child themselves, and they start to restrict. That's the prime time for when anorexia can strike. If they had been left alone, they would have just gained and grown. Now you have to do all this work to get them back to that weight so that they can start to grow again. 

Virginia

I think that's so helpful to normalize. This is what we want our kids to be doing. I'm parenting middle schoolers and I am shocked sometimes how fast a group of 12 year olds can empty the snack cabinet or the ice cream freezer, but this is what we want them to be doing right now. 

When you see that hiding food behavior, parents often think they need to correct that behavior, instead of stepping back and thinking about what led to the hiding. And is this a food that you've given a message they shouldn't have as much of? Or as you're saying, are there other parts in the day where they're not getting enough? I also think a lot about the schedules these kids are under. They're at school all day, then they're going to sports or play rehearsal. My kid was out of the house for 12 hours yesterday. She was starving when she got home, and if you are coming with a diet mindset, you might be alarmed by that. But it completely makes sense that she didn't have enough time to eat during her school day and needed to make up for it. 

Lauren

Yeah. 

Virginia

Well, this is so helpful. Your work is reassuring and grounded. Whether folks are dealing with an active eating disorder or not, if you're parenting teens, if you're working on your own stuff with food, Lauren's work is an incredible resource. The workbook is really great, so thank you for that.

Lauren

Thank you. 

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Butter

Virginia

So we wrap up every episode of Burnt Toast with butter, which is our recommendation segment. Do you have any butter for us today?

Lauren

I've been having a lot of fun with gardening fruit trees in Los Angeles. It's been really fun. I just recently pruned a peach tree to get it ready to hopefully bud and produce fruit. Peach trees have to be shaped in a certain way. You don't want the central leader you've got to have key branches. So I studied, and then you have to reduce the fruit, which is very sad.

Virginia

Oh, you have to cut off baby fruit. 

Lauren

You have to cut off baby fruit because otherwise it just produces too much. You want to select which peaches are going to get bigger. That's been fun. And I'm growing an avocado tree. Pretty soon I have to go outside and spray it with sugar water to encourage the bees.

Virginia

Amazing.

Lauren

To hopefully pollinate it. I love that. I've been hand pollinating my passion fruit vine, which is a whole other thing.

Virginia

I am so jealous that you can do all of this outside. I am currently raising a indoor orange tree because I live in New York and it is 20 degrees today. It is stressful. I have to tell you, Lauren, I don't think she's living her best life right now. I mean, who among us is in this time of year, but I just added a humidifier because I got a hygrometer. She was starting to lose leaves and her humidity was only 22% because it's so cold, even inside my heated house. It's so cold and dry.

So my butter is going to be my humidifier for my orange tree. I'm hopeful, because she's got fruit on her, and it's starting to ripen, but she's dropping leaves because the air is too dry. It's high stakes over here right now with the orange tree.

Lauren

Being able to grow outside. 

VIrginia

It's more logical than what I'm doing, but I just love the idea of fruit trees. We do have, in my garden outside, blueberry bushes, raspberry bushes, all that stuff. But I wanted year round joy.

Lauren

In California we have to get the no freeze hours berries.

Virginia

It's a whole different world over there. Fascinating. Well, yay! Here's for fruit trees for everybody! I don't know if I want to recommend everybody get an indoor fruit tree, because it is quite a project, but she is bringing me a lot of joy, as well as I'm stressing and over there filling her humidifier twice a day.

Lauren

Right? It’s a lot of work to take care of these trees.

Virginia

But I'm on it.

Lauren

I'll be back spraying my avocado tree with sugar to invite the bees.

Virginia

You know what? There's also something to be said for an obsessive hobby right now to just give you a little thing to focus on. I can do this. I can spray this tree with sugar water. Because there's a lot we can't control. So you know what? Fruit tree farming seems like a great use of energy. 

Lauren

And then you get to eat them. 

Virginia

Yes, exactly, and that's what I'm really excited for. And make delicious beverages and whatnot.

Lauren, tell folks where we can find you. How we can support your work.

Lauren

My website is https://www.eatingdisordertherapyla.com/. That's where my group practice information is, and my books are listed there. I have blog with a lot of resources for people with eating disorders, and for parents. My books are available wherever you buy books. They're both by New Harbinger Publications and The Weight-Inclusive CBT Workbook for Eating Disorders is available now.

Virginia

Amazing. We'll link to all of that. Thank you for being here.

Lauren

Thank you so much for having me.

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The Burnt Toast Podcast is hosted by Virginia Sole-Smith and Corinne Fay. You can follow Virginia on Instagram at @v_solesmith and on Bluesky at @virginiasolesmith.bsky.social. You can follow Corinne on Instagram at @selfiefay, on Bluesky at @corinnefay.bsky.social and on Patreon at Big Undies.

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