Eating Recovery Center and Pathlight Summer 2023

LUMINARY

PATIENT OUTCOMES IN HIGHER LEVELS OF CARE

NAVIGATING AMBIVALENCE

8 WAYS TO BUILD AN INCLUSIVE PRACTICE

THE POWER OF Diagnosis

14 TREATING COMPLEX EATING DISORDERS

Experts share insights into diagnosing and treating co-occuring conditions

16 CRUCIAL CONVERSATIONS ABOUT SOCIAL MEDIA

Tips to help providers and parents promote the digital well-being of teens

18 THE POWER OF DIAGNOSIS

How a complete and accurate diagnosis shapes an effective treatment plan

19 REDEFINING GRIEF AND LOSS

A broader definition of grief and loss is changing clinical practice

20 PANDEMIC AFTERSHOCKS: THE KIDS ARE NOT ALRIGHT

Creating safe spaces for kids and teens in crisis

22 NAVIGATING AMBIVALENCE

How providers can turn uncertainty into growth

Illustration by Vanessa Branchi

A Message from

Anne Marie O’Melia, MS, MD, FAAP, CEDS-S she/her/hers

Chief Medical Officer and Chief Clinical Officer

Eating Recovery Center and Pathlight Mood & Anxiety Center

As mental health providers, we are committed to this critical work to help people find true healing and change. And, in doing so, it’s important for us to see each patient as a unique individual, separate from their illness, so we can understand and treat them as a whole person.

To do so, we need to put together the many unique pieces of their puzzle, including that patient’s lived experiences, medical history, current symptoms, family life and home environment. At Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight), we understand just how important it is to provide trusted, comprehensive and whole-person care. That is why our programs are rooted in evidencebased modalities and best practices, delivered by a psychiatrist-led multidisciplinary team. Now, we want to share what we’ve learned with you.

Being a mental health provider today is challenging. Inside this issue of our magazine, you’ll find articles designed to provide valuable and relevant insights that can help your patients achieve true healing and change. Topics include:

• The power of diagnosis

• How research is improving care for patients and families

• Tips to help you and your patients navigate ambivalence

• How to craft an inclusive space for your practice

• Why multidisciplinary team care models are effective

• The importance of patient outcomes in higher levels of care

An Exciting Future Ahead

I joined ERC Pathlight almost nine years ago, and I’m exceptionally proud of all the lives that have been changed by our whole-person approach.

As I envision the future, I see us continuing to explore innovative approaches to care for patients with complex cases. We will continue to consider families and referring providers as an integral part of our treatment teams. We will keep engaging in research to improve outcomes through medical and therapeutic advancements. And we will continue to develop evidence-based training so we can share these innovations with other providers.

The field of behavioral health is changing rapidly, and ERC Pathlight remains committed to advancing the state of science for eating disorders and mood, anxiety and trauma-related disorders in a way that’s never been done before. It’s both an honor and a privilege.

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Ways to Build a More INCLUSIVE PRACTICE 8

How to create safer spaces that represent all identities

Atraditional definition of inclusion is giving everybody a seat at the table. But today, in the field of mental health in particular, that definition is evolving rapidly.

“To me, true inclusion means starting a new table, one that is co-constructed in a way that elevates the perspectives and needs of those who have not been centered before,” says Sand Chang, PhD (they/ them/theirs), a nonbinary psychologist and equity consultant. “This includes people who have lived experiences as BIPOC (Black, Indigenous or people of color), trans, queer, disabled, neurodivergent, fat, poor and other marginalized identities.”

By integrating inclusion, diversity and

belonging within their practices, providers can build safer spaces for patients and families. When they fail to do so, they run the risk of exacerbating mental health disparities. For example, research shows that

• Providers are significantly less likely to ask BIPOC people about eating disorder symptoms than they are white people.1

•Trans individuals are four times more likely to experience a mental health condition than cisgender individuals. 2

•Doctors spend less time with people in larger bodies and fail to refer them for diagnostic tests. 3

Crafting an intentional space for your practice can go a long way toward closing these critical care gaps and developing more

meaningful connections with patients.

“When I walk into a practice as someone in a larger body,” says Meredith Nisbet, MS, LMFT, CEDS-S (she/her/hers), national clinical response manager at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight), “I need to see myself in that room—that it has a chair I fit into and a staff member who looks like me. That signals this is a place that has thought about my needs.”

The eight steps outlined below can help providers develop a more inclusive practice.

1Assess your own biases. Start by examining your own implicit biases. These are the biases that are inherent in each of us.

“Increasing self-awareness about our implicit biases can help prevent us from unintentionally saying or doing something that our clients consider to be culturally inappropriate or offensive,” says Charlynn Small, PhD, CEDS-S (she/her/hers), assistant director of health promotion at Counseling and Psychological Services, University of Richmond.

Harvard University offers an online tool

FIGHTING EATING DISORDERS IN UNDERREPRESENTED POPULATIONS

FEDUP is a collective of trans+, intersex and gender-diverse people who believe eating disorders in marginalized communities are social justice issues. Its mission is to make visible, interrupt and undermine the disproportionately high incidence of eating disorders in trans and genderdiverse individuals. To access FEDUP workshops that will help you create more gender-literate practices, visit www.fedupcollective.org/ training.

called an Implicit Association Test that providers can use to examine their implicit bias. Providers can then challenge those biases by asking themselves open-ended questions, such as: Why do I feel this is true? What evidence do I have to support that? How can I respond as if I didn’t believe that?

“Implicit bias isn’t something to be ashamed about—we all have it,” Nisbet says. “The key is to get curious about it instead of defensive.”

2 Perform an audit.

Look at your physical spaces, including waiting areas or exam rooms. Nisbet recommends considering the following:

• Is the artwork on the walls inclusive?

• Does your staff include people from marginalized identities?

• Can your office chairs accommodate people of all sizes and abilities?

If you’re not sure what to prioritize, you can hire a paid consultant with lived experience in a marginalized identity. “Rely on their expertise to help you create more inclusive programs and offerings,” says Dr. Chang.

3 Embrace cultural humility.

“This approach emphasizes seeking answers instead of making assumptions and is helpful to break down the power dynamic of the provider-client relationship,” Dr. Small says. Cultural humility also means owning your own mistakes, demonstrating respect for different viewpoints and changing your behavior to foster repair.

4 Build an environment of psychological safety.

“Create a space for a person to be their authentic self without judgment,” says Selina Griswold, MSM, MA (she/her/ hers), director of diversity, equity, inclusion,

accessibility and belonging (DEIAB) at ERC Pathlight. This starts with understanding that different lived experiences exist so you can build trust and alliance with patients.

5 Ensure linguistic competency.

The words you and your team use within your practice are just as important as your actions. “Use inclusive language, introduce proper pronoun usage into your practice and make sure you’re not using words that hurt,” Griswold says.

6

Seek different perspectives.

“No one can position themselves as an expert on groups to which they don’t belong,” Dr. Chang says. But providers can reduce this barrier by engaging in the communities of the patients they serve. Join support groups that might identify with a different identity to enhance your learning. Reach out to groups that provide training, awareness and continuing education opportunities in DEIAB.

7 Understand impact over intent.

Your words and actions might have a different impact on people with marginalized identities than you intend for a variety of sociocultural reasons. What is most important is addressing that impact rather than defending your intent.

8 Commit to lifelong discovery.

“Being inclusive requires a commitment to learn about others,” Griswold says. As you navigate your own personal journey toward inclusiveness, be kind to yourself. “Understand that inclusivity is a systemic concern, but that you have a personal responsibility to be part of the solution and not part of the problem,” Nisbet says.

EXPAND YOUR KNOWLEDGE ON INCLUSIVITY

1. https://mhanational.org/racismand-mental-health - Resources and stats on racism and mental health from Mental Health America

2. https://membershare.iaedp.com/Culturally Competent Conversations, held the third Tuesday of each month, from the International Association of Eating Disorders Professionals

3. www.inclusivetherapists.com –A community dedicated to providing equitable access to affirming and culturally responsive mental health care

4. www.apa.org – Inclusive language guidelines from the American Psychological Association

5. www.hrc.org – Healthcare Equality Index benchmarking tool from the Human Rights Campaign

Our Commitment to DEIAB

Griswold launched a strategic roadmap to create a process and structure around ERC Pathlight’s DEIAB strategy. “DEIAB is a journey, not a destination,” Griswold says. “As part of our commitment to fostering a culture that reflects DEIAB, we will continually evolve our strategy to meet the current and future needs of our patients and teammates.”

1.Coffino, J.A., Udo, T., & Grilo, C.M. (2019). Rates of help-seeking in US adults with lifetime DSM-5 eating disorders: Prevalence across diagnoses and differences by sex and ethnicity/race. Mayo Clinic Proceedings, 94 (8), 1415-1426

2. The Trevor Project. (2022). National Survey on LGBTQ Youth Mental Health

3. Phelan, S.M., Burgess, D.J., Yeazel, M.W., Hellerstedt, W.L., Griffin, J.M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews, 16 (4), 319–326

Diversity, Equity, Inclusivity, Accessibility and Belonging CE Events

Scan the code to browse ERC Pathlight CE courses and events focused on DEIAB.

3

Nearly 60 years have passed since chemists first noticed that a monoamine-based tuberculosis drug also appeared to lift symptoms of depression. That discovery, which led to one of the first drugs to treat depression, touched off a cascade of similar medications that modulate neurotransmitters, significantly improving outcomes for countless patients. Today, the latest approaches offer patients more hope than ever before.

Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight) is at the forefront, constantly working to incorporate new medications and modalities into treatment plans.

The latest FDA-approved treatments target the complex nature of eating disorders and mood, anxiety and trauma-related disorders. These new approaches deliver welcome relief for the up to 30.9% of patients with depression1 and up to 50% of patients with PTSD who don’t respond to traditional medications. 2 When combined with comprehensive, evidence-based psychotherapy, these innovative treatments

help clinicians develop individualized paths to recovery.

“We use what works,” says Robert McFerren, LICSW (he/him/his), executive director at ERC Pathlight. “We’re always looking into new modalities.”

Innovations at Work 1 KETAMINE

Ketamine is one of the latest treatments ERC Pathlight has adopted. In 2019, the FDA approved this nasal spray for use in patients with treatment-resistant depression (TRD).

Within hours of administration, ketamine can provide symptom relief that lasts up to a week, though responses vary. 3 Albert Tsai, MD (he/him/his), psychiatrist at ERC Pathlight, explains that most ERC Pathlight patients start ketamine treatment with a score of at least 30, indicating severe depression on the Beck Depression Inventory. After an average of six to eight doses, the score dips into the teens. “We’re making an impact in treating severe depression and trauma, which is so difficult to break through,” says Dr. Tsai.

With traditional antidepressants, patients can struggle for weeks or months waiting for new medication to take effect and hoping it will help. Ketamine fasttracks symptom relief enough to make other treatment modalities, such as cognitive

behavioral therapy, more effective. Ketamine is administered as a medical procedure in controlled dosages (0.5–1 mg for each kilogram of patient weight). Patients remain in the clinic for two hours of observation, during which a nurse monitors blood pressure and for side effects. Treatments are typically given twice per week. While ketamine’s mechanisms of action haven’t been fully explained, research has shown that, as an antagonist, the drug readily binds to NMDA receptors, changing the electrical activity of neurons. The current theory is that the resulting glutamate surge leads to the stimulation of specific neurons and restoration of neuronal connections that were lost due to stress, both of which result in antidepressant effects.4 The new neuronal wiring promotes neuroplasticity, allowing flexible and adaptive thinking.

2 TRANSCRANIAL MAGNETIC STIMULATION

Another innovative treatment offered by ERC Pathlight physicians is transcranial magnetic stimulation (TMS). In this treatment, “a medical device alters electrical activity by applying magnetic fields to the brain regions involved with emotion regulation and cognitive processing,” explains Melissa Mott, MD, PhD (she/her/ hers), psychiatrist at ERC Pathlight.

The FDA approved TMS to treat

A careful embrace of innovative treatments increases the healing possibilities for patients

patients with TRD in 2008 and patients with treatment-resistant obsessivecompulsive disorder (OCD) in 2022. At ERC Pathlight, clinicians use TMS to treat patients with TRD and OCD. About two-thirds of patients with TRD experience symptom improvement while one-third achieve full remission.

Through a magnetic coil on the scalp, patients receive a series of microsecond pulses. Specific protocols have been developed for treating depression and OCD based on research. “When we explain the treatment to patients, we compare TMS to jump-starting a battery,” Dr. Mott says. “We give that region of the brain a boost of energy to get it working properly.”

The current protocols call for a treatment time of three to four minutes for TRD and 18 minutes for treatmentresistant OCD in each session. Patients typically receive 25–30 treatments given

five days a week for five to six weeks. During the procedure, patients feel a scalp sensation and hear a tapping sound. A 2018 study showed that, combined with psychotherapy, TMS decreased Beck Depression Inventory scores by at least half in 66% of 196 patients with TRD, 109 of whom (56%) achieved remission. 5

3 VIRTUAL CARE

It is not widely known that ERC Pathlight was the first treatment provider to offer virtual intensive outpatient programming (IOP) back in 2016. With more than 7,000 patients treated virtually since then, our research shows that a program rooted in best clinical practices and evidence-based treatments, led by clinical experts, delivers exceptional patient experiences and outcomes. Data show statistically significant and clinically meaningful improvements in pathology symptoms, higher completion and attendance rates than on-site IOP, strong connections to peers, and proven effectiveness in treating children and adolescents.

The Importance of New Treatments

As an organization, ERC Pathlight prioritizes the careful integration of emerging FDA-approved treatments. “People are suffering out there,” says Dr. Tsai. “We really want to be on top of FDA-approved treatments and embrace the explosion of new evidencebased approaches.”

McFerren agrees. “The bottom line,” he says, “is that ERC Pathlight providers are inspired by the sentiment that we have a huge responsibility to provide the best service that we can to benefit patients and make their lives better.”

FREE CONSULTATION

Please contact us to make a referral or schedule a free consultation with a master’s-level clinician at 1-877-825-8584. To learn more about ERC Pathlight, visit www.EatingRecovery.com or www.PathlightBH.com

TOOLS TO REBUILD LIFE AFTER TRAUMA

Gloria (she/her/hers), Pathlight alumnus, lives a full life in a Midwest suburb working as a software engineer, volunteering at a local animal shelter and traveling the world. But before she had access to innovative evidence-based treatments at Pathlight, Gloria found herself coping with suicidal thoughts from untreated trauma.

At the age of 12, Gloria was in a car accident that killed her father instantly and left her in a coma with significant injuries. Her family did the best they could, but she was left to pick up the pieces. Overwhelmed with the slew of responsibilities, “I did what I needed to get through,” she says, “like a robot going through the motions.”

Despite devoting herself to school and other pursuits, the trauma, depression and anxiety eventually caught up to her in college when she first experienced suicidal thoughts. Psychotherapy and medications didn’t seem to keep them at bay. That’s when her therapist recommended Pathlight.

Finding Validation

Gloria found trauma group therapy particularly validating because it was her first time being surrounded by others who also had firsthand experiences with trauma. Her therapist gave her tools to manage “overthinking” and challenge upsetting thoughts by reframing them.

Gloria explains that, through Pathlight’s resources and safe environment, she built up a foundation of tools for lifelong management of her PTSD, depression and anxiety. “For the first time,” says Gloria, “I finally found people who understand me.”

1. Zhdanava, M., Pilon, D., Ghelerter, I., Chow, W., Joshi, K., Lefebvre, P., & Sheehan, J.J. (2021). The prevalence and national burden of treatment-resistant depression and major depressive disorder in the United States. Journal of Clinical Psychiatry, 82 (2), 20m13699

2. Institute of Medicine. (2014). Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment. Washington, DC: The National Academies Press

3. Zanos P, et al. (2016). NMDAR inhibition-independent antidepressant actions of ketamine metabolites. Nature, 533 (7604), 481-486

4. Duman, R.S., & Aghajanian, G.K. (2012). Synaptic dysfunction in depression: Potential therapeutic targets. Science, 338 (6103), 68-72

5. Donse L, et al. (2018). Simultaneous rTMS and psychotherapy in major depressive disorder: Clinical outcomes and predictors from a large naturalistic study. Brain Stimulation, 11(2), 337-345

MENTAL HEALTH AND COLLEGE ATHLETES BEHIND THE APPLAUSE:

Facing unique pressure and stressors, athletes require specific approaches to care

Packed schedules. Intense workouts. Pressure from coaches, teammates and fans. Those are three of the many stressors that college athletes experience on top of the pressure facing traditional students. And all of those stressors raise the risk of mental health concerns.

“When you’re a college athlete, you kind of lose the experience of just being a normal student,” says Mazella Fuller, PhD, MSW, LCSW, CEDS (she/her/hers), a social worker at Duke University’s Counseling and Psychological Services. “Sometimes athletes just want to not have to get up at 4 or 5 a.m., go to practice and take care of all the things they have to do.”

Unfortunately, the stressors for college athletes have only multiplied in recent years. One study indicates that 30% of cisgender female and 25% of cisgender male athletes report having anxiety.1 What’s more, a National Collegiate Athletic Association

(NCAA) study conducted from November to December 2021 showed that reports of mental health concerns among college athletes were one-and-a-half to two times higher than historically reported by NCAA athletes prior to 2020. 2

Although two-thirds of student athletes surveyed by the NCAA say they know where to go on campus to seek mental health services, fewer than half (47%) say they would be comfortable seeking support. That’s why it’s important for providers, administrators and athletic departments to send a clear message: Mental health is just as important as physical health.

“A recent rise in the number of mental health advocacy groups for college athletes has helped reduce the stigma associated with mental health,” says Amy Gooding, PsyD (she/her/hers), clinical psychologist at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “But it’s

unfortunate that less than half of athletes say they feel comfortable seeking support on campus.”

“Seeking treatment is a sign of strength, not weakness,” adds Wendy Foulds Mathes, PhD (she/her/hers), director of academic programs and continuing education at ERC Pathlight. “When athletes seek care, they’re standing up for themselves, their team and their community.”

Understanding the Stigma

While an athlete with a physical injury would seldom refuse medical care, the same isn’t true for seeking mental health care.

“Athletes believe they’re supposed to be mentally tough, self-confident and strong. Some fear that if they seek mental health care, they may be perceived as vulnerable or weak in some way,” Dr. Gooding says.

Athletes also face other barriers to care, both perceived and systemic. Some fear that members of their community—their coaches and teammates—will view their choice to seek care negatively. They also worry about getting less playing time or about how treatment may affect their sports performance.

Seeing the Warning Signs

The first step to helping athletes overcome these barriers is to identify when they need help. “The signs of anxiety, depression and eating disorders aren’t much different in athletes than other students, but they present themselves in a different context because of the environment that student athletes live in,” Dr. Foulds Mathes says.

A decline in an athlete’s sports or academic performance is a potential red flag, as are behaviors that isolate athletes from their teams. In addition, athletes who introduce rigid food rules, increase their exercise output or stop eating with the

CERTIFICATION FOR COLLEGIATE PROFESSIONALS

The Eating Disorder Informed Professional course helps coaches, athletic departments, school counselors, professors and more develop tools to support college students at risk for developing eating disorders. To access this on-demand course, scan the code.

team could be displaying signs of an eating disorder.

It’s important to be aware that certain events can increase an athlete’s risk for mental health disorders, including a physical injury or a change in their standing on the team. During midterm and final exam periods, athletes face intensified pressure that also raises risk.

Getting Athletes to Accept Help

Providing appropriate care and resources for college athletes starts by understanding their unique identity. “Many student athletes are goal-directed and solution-focused,” Dr. Foulds Mathes says. “A savvy therapist will understand this and approach their mental health care from that point instead of taking a general approach.”

A great first step is to equate an athlete’s mental health with their physical health. “A lot of times, mental health issues will require individuals to take time away from their sport, so putting mental health and physical health issues on the same playing field is important,” Dr. Gooding says.

Once an athlete is identified as needing help, motivational

interviewing techniques can help them open up—especially athletes who are ambivalent about approaching treatment. “It’s a method of asking open-ended questions—How has this impacted your life? How do you hope things will be different next season?—that helps the athlete explain in their own words why they want to get help,” says Dr. Gooding.

Virtual behavioral health services, such as Eating Recovery and Pathlight At Home, a proven virtual intensive outpatient program (IOP), can make it easier for student athletes to accept care. “With telehealth programs, athletes can get the help they need by just logging onto a computer or phone, no matter how busy their schedule is,” Dr. Gooding says. Another benefit: There’s more privacy around seeking care when you don’t have to visit an on-campus mental health services location for weekly therapy or IOP.

Breaking Down the Stigma

Providers, counselors, athletic directors and school administrators all can play a role in reducing the stigma surrounding mental health among college athletes. For example, when schools have mental health professionals on staff, it’s important for those providers to “show up in spaces where students are,” Dr. Fuller says. “Students should be able to see them in the hallways and visit them in their offices during drop-in hours.”

Student-led groups can also help increase awareness of mental health disorders. For instance, the student-run Duke Body group at Duke University focuses on body image and athletes. “It’s a liberating space for athletes to be their full selves, and we’re there for them,” says Chantal Gil, PsyD (she/her/hers), clinical psychologist and assistant professor in the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine.

The sooner adults who interact with student athletes recognize possible mental health issues, the better the outcome. “If we identify and treat symptoms at a subclinical

SUPPORT FOR COLLEGE ATHLETES

ADVOCATES FOR MENTAL HEALTH IN COLLEGE ATHLETES

Morgan’s Message honors the memory of Morgan Rodgers, a Division I NCAA lacrosse athlete who battled anxiety and depression before dying by suicide at age 22. Morgan’s parents and friends founded Morgan’s Message to equalize the treatment of physical and mental health in athletics. The organization’s goal is to normalize difficult conversations, empower those who suffer in silence and support individuals who feel alone in their struggles. Learn more: www.morgansmessage.org

The Hidden Opponent was founded by Victoria Garrick Browne, a former Division I women’s volleyball player and PAC-12 champion. The organization’s name comes from Garrick Browne’s 2017 TEDxTalk, which detailed her personal battle with depression and anxiety. Endorsed and supported by the late Kobe Bryant, The Hidden Opponent seeks to eradicate the stigma of mental health in sports culture. Learn more: www.thehiddenopponent.org

level, we can prevent the progression to a more severe disorder,” Dr. Gooding says, “allowing college athletes to receive the support they need to improve their overall well-being, get back to their sport quicker and change their life for the better.”

1.The American College of Sports Medicine Statement on Mental Health Challenges for Athletes (Aug. 9, 2021)

2. NCAA Student-Athlete Well-Being Study, Fall 2021 (May 2022)

Eating Recovery and Pathlight At Home, our virtual IOP, was recognized as a best online therapy service by Health, Parents, People magazine and others. This leading program allows students to remain in school and active in athletics while they get the support they need. To learn more, visit www.EatingRecovery.com/AtHome or www.PathlightBH.com/AtHome

Lighting the Way Through RESEARCH

How leading research is improving the quality of patient care

Providing patients with the highest quality care is the driving force behind both research and clinical practices at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). Our team of passionate researchers and clinicians simultaneously advances knowledge while using these findings to refine evidence-based treatments.

ERC Pathlight is particularly well positioned to conduct research. With more than 30 centers nationwide, along with Eating Recovery and Pathlight At Home virtual intensive outpatient program, the organization has guided more than 20,000 patients and their families to recovery.

According to Philip S. Mehler, MD, FACP, FAED, CEDS (he/him/his), chief scientific officer at ERC, founder and executive medical director of ACUTE at Denver Health and professor of medicine at University of Colorado Medical School, this large patient population is perfect for conducting

large-scale, impactful studies.

ERC Pathlight studies cover both the behavioral and medical sides of eating disorders and have included topics ranging from the effectiveness of treatment modalities to the incidence of eating disorders among transgender youth to drug-prescribing practices among psychiatrists.

Often, however, to determine what research questions to pursue, “We look at our patients,” says Howard Weeks, MD, MBA, DFAPA, DFAACAP (he/him/his), chief medical officer at ERC Pathlight. “Our goal is to look at standard-of-care best practices that are accepted in the field and conduct retrospective analyses to prove that they are effective. These are outcomes-based clinical studies based in the real world; they are not clinical trials. We are striving to improve the quality of care for all patients, including those with co-occurring conditions.”

For example, the team’s 2022 study published in the “International Journal of

Eating Disorders” looked at three behaviors associated with eating disorders (purging, binge eating and restricting) to see if one was a better predictor of suicidal ideation (SI), known to be elevated among this population. The study found that purging was the strongest predictor of SI.1

“This finding can then be applied to clinical care by reinforcing screening for suicidal thoughts and risks for patients with an eating disorder characterized by purging,” says Renee D. Rienecke, PhD, FAED (she/her/hers), director of research at ERC Pathlight. “The research gives us important information that we can use to develop more precise treatment plans for certain patients.”

Clarifying Treatment Choices

Research can also shed light on the reasons behind certain behaviors, information that has the potential to clarify treatment choices. To that end, researchers may ask, “Why do some patients engage in binge eating?” or

“What characteristics lead to readmission to treatment?” Answers to these questions have proven to be enlightening through the following studies.

The role of adverse childhood experiences (ACEs) in eating disorders: In a 2022 ERC Pathlight study, researchers compared adult patients who suffered from ACEs with adults from a national sample. The ERC patients had a higher incidence of ACEs than the national sample, and it was mostly patients with binge eating behaviors who fell into this category. 2 The study points to the importance of including trauma-related work in treatment with these clients.

The relationship between diagnosis and risk of being readmitted to higher levels of care: Patients with binge eating disorder or avoidant restrictive food intake disorder were less likely to be readmitted than those with an eating disorder who also had a major depressive disorder diagnosis or a history of self-harm. 3

A Game-Changing Study

Eating disorders have multifaceted causes and ramifications, and in some cases biology plays an important role and should not be overlooked. “I’ve been watching research evolve over many years and have seen a shift from an extreme focus on sociocultural factors toward a focus on genetics and biology,” says Harry A. Brandt, MD (he/him/his), chief of medical operations at ERC Pathlight. “It is clear that our culture encourages dieting and thinness, but eating disorders have strong biological underpinnings that must be better understood.”

A vivid example of the importance of biology in treating patients with eating disorders was the long-held—though not yet proven—belief that the time it takes for the heart to contract and relax, known as prolongation of the QTc interval, was an intrinsic part of anorexia nervosa. Knowing whether this theory is correct is important as this condition can lead to

RESEARCH IN ACTION

cardiac arrest and death.

A team of ERC Pathlight and University of Colorado physicians led by Dr. Mehler set out to address this question. Over 15 years, with a number of publications, the team found that a prolonged QTc interval is not an inherent part of anorexia but is in fact due to secondary causes.

“This finding is significant because instead of automatically ascribing the prolonged QTc interval to the anorexia nervosa and assuming it would get better when the anorexia nervosa improved—an approach that may have led to unnecessary deaths—physicians now have to stop, look for the cause of the abnormal QTc interval and then correct it,” explains Dr. Mehler. “Typically, it is the result of abnormal electrolytes or the medications prescribed. By defining the cause of this abnormality—as proven by research—it then becomes possible to correct it.”4

ERC Pathlight is continuing to build its portfolio of research. “There is a dearth of research on patients in higher levels of care,” notes Dr. Rienecke. “We have to be careful not to act prematurely; over time, we believe that our work will continue to have a significant impact on the quality of patient care.”

1. Joiner, T.E., Robison, M., McClanahan, S., Riddle, M., Manwaring, J., Rienecke, R.D., Le Grange, D., Duffy, A., Mehler, P.S., & Blalock, D.V. (2022). Eating disorder behaviors as predictors of suicidal ideation among people with an eating disorder. International Journal of Eating Disorders, 55(10), 1352-1360

2.Rienecke, R.D., Johnson, C., Le Grange, D., Manwaring, J., Mehler, P.S., Duffy, A., McClanahan, S., & Blalock, D.V. (2022). Adverse childhood experiences among adults with eating disorders: Comparison to a nationally representative sample and identification of trauma profiles. Journal of Eating Disorders, 10 (1), 72

3. Gorrell, S., Le Grange, D., Hutchinson, V., Johnson, M., Duffy, A., Mehler, P.S., Johnson, C., Manwaring, J., McClanahan, S., Blalock, D.V., & Rienecke, R.D. (2022). Care utilization in eating disorders: For whom are multiple episodes of care more likely? Eating and Weight Disorders, 27(8), 3543-3551

4. Krantz, M.J., Blalock, D.V., Tanganyika, K., Farasat, M., McBride, J., & Mehler, P.S. (2020). Is QTcinterval prolongation an inherent feature of eating disorders? A cohort study. American Journal of Medicine, 133(9), 1088-1094

Data show that eating disorder patients in a five-day partial hospitalization program (PHP) lose weight over the weekend. Now, ERC only offers seven-day PHP programming to prevent regression, providing an insurance-backed standard of care. Download your seven-day PHP resource guide.

RESEARCH HIGHLIGHTS

Research and patient outcomes data in virtual intensive outpatient programs (IOP): Based on clinical outcomes data and a research study submitted for publication, the data show the efficacy of ERC Pathlight’s virtual IOP, including patient experiences, attendance and outcomes. Study authors: Michel, D.M., O’Melia, A.M., Mathes, W.F., & Tallent, C.N.

In addition to our team’s findings, the eating disorder community published a wide variety of articles in 2022. Below are two notable examples.

What next for eating disorder genetics? Replacing myths with facts to sharpen our understanding: There are many misconceptions about who can develop an eating disorder, which can have a negative impact on genetics research. This study methodically explains the range of people who can develop eating disorders, including all genders, ages and body types. Authors: Huckins, L.M., Signer, R., Johnson, J., Wu, Y.-K., Mitchell, K.S., & Bulik, C.M.

Epidemiology of eating

disorders among US adults: This study provides a look at the sociodemographic characteristics of eating disorder patients, suggesting that LGBTQ+ patients and those with adverse childhood experiences may be at higher risk. Authors: Udo, T., & Grilo, C.M.

THE IMPORTANCE OF PATIENT OUTCOMES

Why they matter and how they inform clinical care

From the time a patient is admitted to when they “step down” to a lower level of care or discharge, Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight) uses scientifically accepted assessment tools to measure progress and the overall impact of treatment. While this is a standard best practice for all ERC Pathlight programs, it sets the treatment center apart as a leader in collecting and interpreting data on patient outcomes.

Below are some frequently asked questions about outcomes-based research. The ERC Pathlight research team responds, sharing insights about the importance of this process.

1What tools does ERC Pathlight use to collect information?

ERC Pathlight uses different tools to collect data. For eating disorders, the Eating Disorder Examination Questionnaire (EDE-Q) Global Score looks at general eating disorder thoughts and behaviors, as well as accompanying subscales. The subscales measure attempts to restrict food, along with concerns about eating, weight and shape. ERC Pathlight also uses the Patient Health Questionnaire-9 (PHQ-9) to measure depression and the General Anxiety Disorder-7 (GAD-7) assessment tool to measure anxiety for both patients with eating disorders and those with mood and anxiety disorders.

Renee D. Rienecke, PhD, FAED (she/her/hers), director of research at ERC Pathlight, notes that children and adolescents receive different questionnaires than adults. Because of ERC Pathlight’s emphasis on family involvement in treatment, parents of children and adolescents also complete questionnaires measuring constructs such as family functioning and expressed emotion, which has been shown to play an important role in treatment for children and adolescents.

2 How are the data interpreted?

The data collected at ERC Pathlight are viewed through two lenses—changes in symptoms from admission to discharge and effect size—an additional layer not usually addressed by treatment centers. Effect size goes beyond statistical significance and measures the practical implications of an outcome.

Craig Johnson, PhD, CEDS, FAED (he/him/his), senior clinical advisor at ERC Pathlight, explains that, in general, “larger effect sizes mean that patients, on average, made clinically significant progress

toward recovery.” ERC Pathlight has another advantage in its data collection process: a large volume of patients across the nation with an 80-90% questionnaire response rate. Howard Weeks, MD, MBA, DFAPA, DFAACAP (he/him/ his), chief medical officer at ERC Pathlight, notes that this high quantity of patient data means that the information is more statistically sound.

3How is the information used?

OUTCOMES DATA

Scan the code to learn more about our patient outcomes and research team.

The data are collected primarily to inform clinical care. In addition, the data can be used retrospectively for clinical quality research. To use the data, all research studies follow the rules set by the Institutional Review Board, which is designed to protect patients’ rights. “In effect, the research data are separated from the clinical data and stripped of identifying information to protect patient privacy, the standard used for all research projects,” says Dr. Weeks. “By standardizing the collection of outcomes data, we are able to produce a large database that allows us to explore associations and causations in clinical treatment.”

A new capability has recently been added to ERC Pathlight’s computer system: Data from the questionnaires can flow directly to a patient’s chart, providing “real-time information that can be used to develop treatment plans,” says Dr. Johnson. He adds that a data stream from an app called Recovery Record is providing even more information. “Patients can use the app to record their eating habits, exercise regimens and overall feelings about recovery while they’re in treatment and when they go home,” he explains. “This tool allows clinicians to stay in touch with their patients after discharge and has tremendous research potential.”

4 Has there been information from outcomes data that has affected treatment protocols for patients?

Yes. For example, “Our data showed that over half of our adult patients have PTSD symptoms at admission, with significant improvement over the course of treatment,” says Dr. Rienecke. “We already carefully

TREATMENT THAT WORKS: POSITIVE OUTCOMES FROM ERC PATHLIGHT

The charts below outline truly compelling positive outcomes across ERC Pathlight’s treatment of eating disorders, depression and anxiety among adults, children and adolescents. At ERC (Charts A and B), scores from the EDE-Q questionnaire showed significant improvement on all measures from admission to discharge for both populations, as was the case with measures of depression and anxiety. Similarly, the Pathlight results from the PHQ-9 and the GAD-7 assessments (Chart C) showed significant clinical improvement in depression and anxiety, respectively. The caption for each chart explains these findings in more detail, showing how the data create a picture of success from ERC Pathlight’s treatment.

EDE-Q Outcomes for Adults and Children & Adolescents (C&A) at Eating Recovery Center

Depression and Anxiety Outcomes for Adults and C&A at Eating Recovery Center

Depression and Anxiety Outcomes for Adults and Adolescents at Pathlight Mood & Anxiety Center

A. Data from 1,611 adult patients and 885 child and adolescent patients collected from 2020 to 2022 showed clinically significant improvements in eating disorder symptoms.

B. Data from 996 adult patients and 570 child and adolescent patients collected from 2020 to 2022 showed clinically significant improvements in symptoms of depression (PHQ-9) and anxiety (GAD-7). Patients reported a reduction in depression symptoms, from moderate/ moderately severe to mild/moderate, and anxiety symptoms, from moderate to mild, over the course of treatment at Eating Recovery Center.

C. Data from 321 adult patients and 225 adolescent patients collected from 2020 to 2022 showed clinically significant improvements in symptoms of depression (PHQ-9) and anxiety (GAD-7). Patients reported a reduction in depression symptoms, from moderate/moderately severe to mild/moderate, and anxiety symptoms, from moderate to mild, over the course of treatment at Pathlight Mood & Anxiety Center.

screen for trauma at admission, but this finding may guide other similar treatment programs to screen for trauma and incorporate trauma-informed care into their treatment.”

Another change made based on data is the extension of the partial hospitalization eating disorder treatment program, referred to as PHP, from five days a week to seven. “Clinicians had known that patients often lost weight over the weekend in five-day-a-week programs,” says Dr. Weeks. “ERC designed our program to be seven days a week to prevent that regression and to improve outcomes.” What’s more, the data and subsequent articles published objectively demonstrated improved outcomes for our patients. Over time, a seven-day-a-week PHP was adopted as a standard of care in eating disorder treatment programs and is supported by insurance companies because they see the positive outcomes.

5 What challenges do you continue to face in collecting outcomes data?

Collecting data is hard, and it is a significant time commitment for the patient, family and treatment team. But the investment is well worth it. “Outcomes data is how we can show objectively and transparently that the treatment is working and patients are getting better,” says Dr. Weeks. Dr. Johnson agrees, adding, “Our goal continues to be to challenge ourselves to improve how we collect information so that we can track whether our outcomes are improving.”

Dr. Weeks concludes, “We are constantly striving to find more efficient and better ways to make the data useful to patients and clinical teams so that everyone recognizes the value in collecting this information.”

TREATING COMPLEX EATING DISORDERS

Experts share insights into diagnosing and treating co-occurring conditions

Eating disorders are complex. The presence of other psychiatric conditions—most commonly anxiety (up to 62%), mood disorders (up to 54%), post-traumatic stress disorder (up to 27%) and substance use (up to 27%)—can drive diagnostic complexity and create challenges in the treatment of eating disorders.1 “Patients with co-occurring disorders struggle with higher levels of psychological dysfunction and often require multiple interventions at once,” says Kris Ramos, MSW, LCSW (she/they), clinical director at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “They also may experience several readmissions, circulating throughout outpatient and residential care.”

Elizabeth Wassenaar, MS, MD,

CED-S (she/her/hers), regional medical director at ERC Pathlight, agrees. “Patients with co-occurring conditions, especially obsessive-compulsive disorder (OCD) or mood disorders, can present additional treatment challenges and may struggle to stay in treatment.” The age at which someone develops an eating disorder or co-occurring condition and the length of time they struggle can both contribute to the complexity of their disease and impact the recommended course of treatment.

To help patients find relief as quickly as possible, diagnosing co-occurring disorders is key. “It’s harder to diagnose mood and anxiety disorders in patients with eating disorders because you’re asking which came first,” says Em Markovich, MEd, LPC-S

(they/them/theirs), clinical director at ERC Pathlight. “These conditions exist within each other. In my work with kids, we see the OCD symptoms shift away from food to other things once their weight has stabilized. At that point, we have a better chance of diagnosing the anxiety disorder.”

Ramos calls the push and pull between eating disorders and mood and anxiety disorders the “whack-a-mole” effect, where addressing the eating disorder leads to something else cropping up. This is often because the patient is no longer using food behaviors to cope. “Once we stabilize the eating disorder, self-harm may increase; or if substance use is under control, then the eating disorder may flare up,” she says. “We see this process repeat itself again and again.”

At ERC Pathlight, one reason we can effectively treat these patients is that we treat them in a setting where we can monitor their ability to engage in maladaptive behaviors. At the same time, we provide the medical, psychiatric and psychological support they need to create long-lasting behavior change.

It Takes a Specialized Team

For complex cases, it’s especially important that a multidisciplinary team be in place. ERC patients have a team that includes a primary care physician, psychiatrist, therapist and dietitian collaborating every step of the way. “Our team meets at least once a week independently and with the patient once or twice a week,” says Ramos.

Typically, the treatment plan includes different modalities to address the patient’s specific symptoms. For example, if a patient is diagnosed with OCD, which can be more common in patients with anorexia nervosa or avoidant restrictive food intake disorder, exposure and response prevention (ERP) therapy is often effective. Recognized as an evidencebased, first-line treatment for OCD, ERP carefully exposes patients to the thoughts, images and situations that provoke their obsessions and compulsions, with the goal of reducing the anxiety associated with them.

If a patient presents with cooccurring self-harm or emotion dysregulation, dialectical behavior therapy may be the treatment of choice. This model guides patients through a series of steps in which they analyze their thoughts and behaviors and come to terms with painful elements in their

lives that they cannot change. Patients then learn how to cope with their feelings and are equipped with tools to build strong, healthy relationships.

For children and adolescents, therapeutic interventions for cooccurring conditions augment family-based treatment, an evidencebased approach for the treatment of eating disorders that is highly effective for young people. “We empower parents and caregivers to lead the weight restoration process for their child,” explains Markovich. “During this process, we educate the parents and caregivers as well as the patient. When feelings such as fear, grief and frustration come up, we integrate an innovative modality called emotionfocused family therapy. In addition to behavioral strategies to address the disordered eating, caregivers learn how to identify and support both their emotions and their child’s. It’s a powerful form of therapy.”

“Eating disorders and accompanying symptoms are like layers of an onion,” says Ramos, “and the more layers you uncover, the closer you get to identifying their root causes. This can be an overwhelming process, which is why treatment at higher levels of care is so specialized—where therapists should be trained in multiple treatment modalities, and where patients should expect their psychiatrist, therapist, dietitian and physician to be working together at all times to guide them toward recovery.”

FLYING UNDER THE RADAR One Woman’s Story of Anorexia in a Larger Body

From the time Joanna Nolen (she/her/hers), ERC alumnus and Recovery Ambassador Council member, was a child, she constantly heard about her weight. As a child in a larger body, her parents worried she would develop diabetes or cancer—diseases that ran in her family—and strongly encouraged her to watch what she ate and to exercise.

On top of the pressure she felt at home, she was also made fun of at school because she didn’t look like the other girls in her class. By the time she graduated from high school, she had internalized the message that the only way to fit in was to be thinner.

“I started exercising a lot, and when my peers started recognizing me because of my weight loss, I started restricting my food, and then I got hooked on laxatives and diet pills,” Nolen recalls. “There was even one Christmas when I spent the evening on the elliptical machine. I was determined to be the person society wanted me to be.”

Nolen started to realize that something was wrong when, as a sophomore in college, she developed a severe pain in her stomach and had to go the emergency room. “The doctor asked me if I had a history of an eating disorder, but he didn’t follow through. There was no diagnosis or treatment plan. He just told me to eat more.”

Even after that episode, a few years went by before Nolen sought treatment. It wasn’t until her anxiety, depression and eating disorder behaviors became unmanageable that she went to see her doctor, who referred her to a cognitive behavioral therapist. The therapist recommended that she go to ERC for the treatment of her complex eating disorder and co-occurring conditions.

“The therapists at ERC pushed me out of my comfort zone,” Nolen says. “Learning to live with being uncomfortable was an essential part of the treatment. As I opened up, I became more vulnerable, but I felt less alone.

PARTNER WITH ERC ON COMPLEX CASES

We excel at treating patients with complex eating disorders across our continuum of care including inpatient, residential, PHP and IOP (in-person and virtual). To make a referral or schedule a free assessment with a master’s-level clinician, call 1-877-825-8584

We excel

“Living in a larger body allowed me to fly under the radar for a long time,” she continues. “I didn’t look like what both the medical community and society deemed someone with an eating disorder should look like. But I got past that, and now I have the tools to be in charge of my life and not let my eating disorder control it.”

1.Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: Findings from a rapid review of the literature. Journal of Eating Disorders, 10 (1), 132

About Social Media Crucial Conversations

Tips to help providers and parents promote the digital well-being of teens

Social media is an ingrained part of everyday life. Nearly all adolescents ages 13-17 (94%) say they’re online “almost constantly” or “several times a day.”1

While social media can promote connection among teens, it also brings risks, like cyberbullying and engaging with accounts that promote eating disorders or self-harm. That’s why it’s so important for both providers and parents to help adolescents set healthy boundaries around social media use.

“Asking a teen not to be connected on social media is like asking them not to be

connected to their peers,” says Alyssa Lucker, DO (she/her/hers), child and adolescent psychiatrist at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “But we can educate teens on how to engage in social media safely.”

What Research Shows

Social media can create a healing space for community and connection, with clinical research citing self-expression, social support and personal growth as benefits. 2 At the opposite end of the spectrum, exposure to misinformation, divisiveness,

violence and other mature content can cause significant harm to kids and teens. The impact of social media use in general— checking to see what friends, family and favorite businesses are doing or watching entertaining videos—is less clear.

“There isn’t a ton of longitudinal research to tell us cause and effect,” says Dr. Lucker. “We don’t know for sure, for example, if teens who spend more time on social media become more depressed, or if teens struggling with mental health issues are the ones who spend more time on social media.”

Having the Conversation

Below are seven ways to help teens set boundaries and improve their relationship with social media.

1 Open the lines of communication. The key is starting an open dialogue with teens centered around what they enjoy about social media and how they feel when they use it. “When you approach it with a curious mindset, you open up the space for real conversation,” says Sally Fleck, PhD (she/her/hers), clinical manager at ERC Pathlight.

2 Address safety and privacy concerns. Stress the importance of keeping personal information private, such as not sharing full names or addresses and turning off location-enabled services. Also, emphasize that your child can come to you immediately if they ever do feel unsafe on social media.

3 Set flexible boundaries. Start small, with no phones at the dinner table or limiting screen time before bed. “If boundaries are too rigid—such as making teens disconnect totally—adolescents will get on their friends’ phones at school and engage in social media in a way that is secretive,” Dr. Fleck says.

4 Consider time limits. Try 30-minute increments of social media use after school and go from there. “Set their phone to ping them once they’ve reached the limit as a reminder,” Dr. Fleck says. Resources like the American Academy of Pediatrics website have a family media plan that can help parents and providers set appropriate limits based on a variety of factors unique to each family.

5 Keep it real. Remind adolescents that the images and personas they see others portray on social media are curated

most of the time. “You’re only seeing what other people want to show you,” Dr. Lucker says. Because of this false reality created, social media can negatively affect a person’s self-perception.

6 Encourage a self-audit. “Ask a teen to take a five-minute pause before and after each social media session and write down how they feel,” Dr. Lucker says. Doing so will help adolescents become more mindful about their social media use and how it impacts them. Parents can model healthy behaviors and conduct their own self-audits alongside teens.

7 Embrace a values-based approach. “Help teenagers align their social media feed with what’s most important to them—family, friends, art, volunteering,” Dr. Fleck says. “This will help them develop an internal compass they can use to self-govern their social media use.”

Red Flags to Watch For

While every child responds differently, there are certain changes in behavior that can serve as red flags that a teen’s social media use has crossed over into unhealthy territory.

Changes to basic hygiene “If a teen who was showering daily and brushing their teeth twice a day is now slipping in their basic hygiene routine,” says Dr. Lucker, “it might indicate social media is impacting their dayto-day functioning.”

Sudden shift in mood and irritability

While mood changes are common at this age, it is important to note if a teen is more moody or irritable during or after engaging with social media.

Pulling away from family. Similarly, while it can be healthy for teens to seek independence, it is concerning if someone has abruptly stopped engaging in family activities or seems generally closed off from loved ones.

Defensive about social media use. It is a significant red flag when teens clam up if you

WHY SOCIAL MEDIA IS ONLY #HALFTHESTORY

When teens scroll through their social media feeds, they only see part of the picture—the part that people want to share with them. It’s a message that the not-for-profit organization #HalfTheStory shares through advocacy, community and education, including a four-week Social Media U course designed to help teens take control of their tech use. Scan the code to learn more.

ask about social media. “If teens are mature enough to be on social media,” explains Dr. Lucker, “then they are mature enough to have a conversation with their parents about how they are using it.”

By following these tips, parents and providers can help adolescents engage in safe practices on social media while still gaining the sense of connection and belonging that they crave.

1.Pew Research Center. (2022). Teens, social media and technology

2. Riehm, K.E., Feder, K.A., Tormohlen, K.N., Crum, R.M., Young, A.S., Green, K.M., Pacek, L.R., La Flair, L.N., & Mojtabai, R. (2019). Associations between time spent using social media and internalizing and externalizing problems among US youth. JAMA Psychiatry, 76(12), 1266-1273

RECOVERY COMMUNITY FOR YOUR PATIENTS

Our Say It Brave online community offers a safe and inclusive space for kids and teens to foster connection, access resources and help end mental health stigma. Check out upcoming events featuring recovery advocates leading candid, crucial conversations about mental health.

THE POWER OF DIAGNOSIS

Diagnosis is a powerful tool and is the first step in developing and monitoring an effective treatment plan for eating disorders and mood, anxiety and trauma-related disorders. “The initial diagnosis can help patients focus on what is happening to them, what may be contributing to the problem and what can be done about it,” says Ellen Astrachan-Fletcher, PhD, FAED, CEDS-S (she/her/hers), regional clinical director at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “The diagnosis is an important part of the process, and sometimes I don’t think we give it the attention it deserves, including for co-occurring conditions.”

Thorough Assessment Is Key

To ensure that each patient’s diagnosis is as accurate as possible, ERC Pathlight has a multistep diagnostic process. It begins with a comprehensive assessment conducted by a master’s-level clinician before the patient is admitted. “Our intake assessment is important for providing level-of-care recommendations to guide patients into the most appropriate program,” says Rebecca Linehan (she/her/hers), director of admissions at ERC Pathlight. “It sets the course of their treatment and recovery.”

Following admission, ERC Pathlight’s multidisciplinary team, including a primary care physician, psychiatrist, therapist and dietitian (for our eating disorder patients), performs extensive psychiatric, medical and psychosocial evaluations. Their goal is to identify the primary and co-occurring conditions, such as obsessive-compulsive disorder or substance use disorders.

“Our transdiagnostic care approach includes a comprehensive assessment that enables us to identify symptoms and behaviors that may have been previously overlooked, allowing us to treat the whole person effectively,” says Kim Anderson, PhD, CEDS (she/her/hers), executive director at ERC Pathlight.

The benefit of ERC Pathlight’s approach is that the team never stops collecting and evaluating new information as it becomes available. For example, Dr. Anderson recalls a patient diagnosed with

a recalls master’s-level

FREE ASSESSMENT

avoidant restrictive food intake disorder, known as ARFID. For the first few weeks of treatment, the focus was on increasing food intake and volume through familybased treatment and exposure therapy. In particular, the exposure therapy addressed the sensory sensitivities the patient associated with food and the accompanying feelings of disgust about certain food textures. The treatment was successful in that she started gaining weight. “But then, this patient started expressing concerns about how the weight gain was making her feel uncomfortable in her body,” says Dr. Anderson. “At that point, the diagnosis shifted to anorexia, and we started doing body image work. She responded very well.

“The important message here is that the team noticed the change and modified treatment accordingly,” adds Dr. Anderson. “In this way, both diagnosis and treatment continue to evolve.”

Meeting Patients Where They Are

Clinicians should be prepared to validate and hold space for a wide range of reactions when they share any diagnosis with patients and their families. “Some people will feel relieved that they have an illness that has a name and can be treated,” says Dr. Anderson. “Others may feel shocked and scared, overwhelmed by what the diagnosis will mean for their lives, or have trouble accepting it. Those people should be continuously reassured to not blame themselves or feel guilt and shame because of the diagnosis.” They can also be given education that helps them overcome the stigma they may associate with their diagnosis. This process isn’t a “one and done” discussion but an ongoing part of treatment.

Diagnosis is an integral part of the healing process. It opens the door to effective, appropriate treatment. Importantly, it’s also a turning point for many patients. “Many patients have said that following the diagnosis, they felt understood,” says Dr. Astrachan-Fletcher. “That’s a powerful way to begin therapy.”

Please contact us to make a referral or schedule a free consultation with a master’s-level clinician at 1-877-825-8584. To learn more about ERC Pathlight’s treatment programs, visit www.EatingRecovery.com or www.PathlightBH.com

How a complete and accurate diagnosis shapes an effective treatment plan

REDEFINING GRIEF AND LOSS

A broader definition of grief and loss is changing clinical practice

When most people think of grief, they assume it involves mourning the loss of a loved one for a finite period. Over the past few decades, however, the way clinicians define grief and loss has evolved, changing how they guide patients through their unique journeys.

Kaylee Kron, LMSW (she/her/hers), national community partnership manager at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight), follows a broader definition encompassing a range of losses, from divorce to moving to the collective losses we all suffered during the COVID-19 pandemic. She defines grief and loss as “a response to something being taken away from you, with or without your permission.”

Embedded in any loss are unexpected changes that must be acknowledged and grieved. “A divorce may bring about a loss of identity, income and friendships that must be honored through the grieving journey,” says Kron.

To help patients grapple with their loss, several tools are available. Worden’s tasks of mourning provide a framework that includes accepting the loss, processing the pain and embarking on a new life while finding an enduring connection with the loss. These tasks don’t have to be addressed in any order, and they can be revisited at different points in time.1

“I will meet my patients wherever they are in their journey,” says Kron. “This means sitting in the messy middle with each person, ensuring that they are seen, heard and understood.”

Grief Through a Sociocultural Lens

Meeting patients where they are also means understanding their grief and loss from a sociocultural perspective and acknowledging that many have experienced trauma.

Bernasha Anderson, MEd, PhD (she/ her/hers), a clinical psychologist in private

BODY GRIEF: ONE WOMAN’S JOURNEY

Jayne Mattingly (she/her/hers), Say It Brave Collective member at ERC Pathlight, founder of The AND Initiative and soon-to-be author, was on a roll. She had completed her master’s degree in clinical mental health counseling, recovered from her eating disorder and was finding peace in her body. “Then, bam,” she recalls, “Some new physical problems piled up, leaving me disabled at the age of 28.”

Struggling to adjust to these unexpected changes, Mattingly revisited a term she coined early in her career—body grief, associated with body changes, whether in appearance or functionality, which can come with puberty, eating disorders, physical disability and more.

Naming her feelings as grief was empowering. To cope with difficult moments, Mattingly may have a good cry or take a warm shower. “My aim is to feel 1% to 5% better rather than 100% better,” she says. “That’s a reasonable goal.”

To learn more about Jayne’s book “This Is Body Grief,” coming spring 2025, visit www.JayneMattingly.com

practice and co-facilitator of group support sessions at The Loveland Foundation in partnership with ERC Pathlight, has a wider perspective on grief and loss from her work with Black women and nonbinary people. Trauma and grief are intertwined, but they are not the same. “While sexual assault is a trauma, the associated grief could be the loss of the relationship you had or mourning the safety you once shared with your body,” Dr. Anderson explains. “People with marginalized identities may be impacted by multiple levels of trauma and may experience systemic oppression, intergenerational and/or race-based trauma.”

To work through grief and trauma, Dr. Anderson believes that traumatic experiences and losses can be given a name, which validates the pain and encourages healing, further facilitated by support groups. “By sharing stories,” she explains, “clients affirm and empower each other to honor their grief and loss toward healing.”

Redefining grief and loss can help therapists expand their perspective—and their practice.

1.Worden, J.W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner (fifth ed.). New York: Springer Publishing Company.

RESOURCES FOR YOU AND YOUR PATIENTS

To learn more about how you can support your patients through their healing journeys, read ERC Pathlight’s blog “Grief and Mental Health: A Clinician’s Guide to Supporting Patients in Grief.”

PANDEMIC AFTERSHOCKS: The Kids Are Not Alright

parents and caregivers can create safe spaces for kids and teens in crisis

FAMILIES ASK WE ANSWER

At our monthly virtual open house, parents and caregivers learn more about mental health treatment for their kids and teens in crisis. Scan the code and share with your patient’s loved ones so they can get their questions answered.

The COVID-19 pandemic robbed kids of many typical childhood and teenage experiences, from mundane activities to milestones. The losses were great, and while society may be ready to put the pandemic in the rearview mirror, the reality is that our kids are still feeling the aftershocks and need support.

“Social isolation, leading to increased use of social media, accompanied by limited access to youth sports and other activities, resulted in short- and long-term psychosocial and mental health implications for children and adolescents,” says Elizabeth Easton, PsyD, CEDS (she/her/hers), national director of psychotherapy at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “Furthermore, due to school closures, children and adolescents were not afforded the same in-person learning opportunities, and those with medical vulnerabilities experienced even greater adjustment issues or mental health concerns.”

For many kids, the pandemic may have also been the first time they lost a loved one and experienced grief—another trigger for mental illness. According to a 2021 meta-analysis, depression among kids and teens doubled during the first year of the pandemic, rising to nearly 25%. The same was true for anxiety, with rates climbing to about 20%.1 The prevalence of eating disorders also increased. One study from a pediatric hospital in Michigan showed that eating disorder admissions more than doubled compared to pre-pandemic levels. 2

“The lack of control over what was going on in the world proved to be a trigger for young people at risk for eating disorders,” notes Delia Aldridge, MD, FAPA, CEDS-S (she/her/ hers), medical director at ERC Pathlight. “Kids saw family members lose their jobs, and there was limited access to resources. With everyone in lockdown, isolation was acute, and young people experienced a pervading sense of fear and anxiety. Eating disorders thrive under these conditions.”

Just as each generation was impacted by the pandemic in different ways, we are healing at different speeds, and kids and teens need more support than ever.

The Right Treatment at the Right Time

When a mental health disorder becomes so acute that outside help is needed, parents and caregivers play an important role in treatment and recovery.

How

Katie Kittredge (she/her/hers), ERC alumnus, knows this from firsthand experience. When she developed an eating disorder at the beginning of high school, her parents were her lifeline. “They saw the signs and sought help from a friend, who recommended ERC,” says Kittredge. “During my recovery, my parents were making many medical decisions for me, which was hard. I wanted to be in control. My eating disorder was driven by that desire. Over time, I realized that I had goals outside my eating disorder and wanted to think about college and other things, not just about food. As I moved away from my disorder, I regained control of my life.”

The earlier a mental health disorder is recognized, the more effective treatment can be, increasing the likelihood of lasting recovery. Research suggests that outcomes are better if treatment is started within the first three years of the onset of the illness. 3

For teens like Katie Kittredge, ERC Pathlight provides individualized treatment plans that meet them where they are. When a patient comes to ERC Pathlight for treatment, the first step is determining the level of support needed. A master’s-level clinician conducts a comprehensive assessment and makes a recommendation about what level of care they need. A multidisciplinary team, including a primary care physician, a psychiatrist, an individual and family therapist, and a dietitian (for eating disorder patients), then determines an individualized treatment plan using a variety of evidence-based treatment approaches.

Throughout treatment, parents and caregivers are involved and supported at every step. Family-based treatment, used in conjunction with emotion-focused family therapy, empowers parents, caregivers, and children and teens to learn tools to lean into the feelings that are arising and create behavior changes. Depending on the diagnosis, other modalities are used. For example, if the patient has an anxiety or mood disorder, the treatment may involve cognitive behavioral therapy (CBT). CBT focuses on how thoughts and beliefs can contribute to anxiety and depression; similarly, behaviors and reactions

can also trigger those feelings. CBT works on both sides simultaneously and is a highly effective form of therapy.

The Lasting Impact of Treatment

These therapeutic approaches have proven to be long-lasting over time, especially with ongoing parental support. Kittredge’s experience is a case in point. She was a senior in high school when the pandemic hit, but by then she had the tools to deal with this stressful time. As a result, she didn’t relapse during this period. “It changed a lot about my senior year,” recalls Kittredge. “Prom and graduation were both canceled, but I had my parents, friends and a supportive community in place. We were still able to have fun.”

For all children and adolescents, it is essential to have coping strategies and tools to help get through the ups and downs of life, especially during challenging times. The people most likely to provide young people with these tools are parents and caregivers. Communication is key, but knowing what to say and how to say it can be challenging.

Dr. Easton of ERC Pathlight has the following tips you can share with parents:

• Establish consistency. Create a routine with your child or teen that they can count on.

• Create a safe space. Have open conversations about their feelings and concerns, and validate those emotions without jumping to solutions.

• Build connection. Show interest in their world and what excites them (i.e., hobbies or music).

“Supporting kids on a daily basis and when they’re in crisis is a family affair,” says Dr. Aldridge. “This means helping them have positive interactions and develop coping skills, both of which build resilience and confidence. Ultimately, that’s the outcome we’re looking for.”

1. Slomski, A. (2021). Pediatric depression and anxiety doubled during the pandemic. Journal of the American Medical Association, 326 (13), 1246

2. Otto, A.K., Jary, J.M., Sturza, J., Miller, C.A., Prohaska, N., Bravender, T., & Van Huysse, J.L. (2021). Medical admissions among adolescents with eating disorders during the COVID-19 pandemic. Pediatrics, 148 (4), e2021052201

3. Treasure, J., & Russell, G. (2011). The case for early intervention in anorexia nervosa: Theoretical exploration of maintaining factors. British Journal of Psychiatry, 199 (1), 5-7

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REFRAMING THE CONVERSATION: TALKING WITH A CHILD ABOUT THEIR EATING DISORDER

When parents are dealing with their child’s eating disorder, they are willing to do anything to help their child overcome it. But when a child is malnourished, their brains are not functioning properly, and having constructive conversations about better nutrition and weight improvement is not always easy. That’s where a concept called “brain rescue” may be helpful. Developed by Ovidio Bermudez, MD, FAAP, FSAHM, FAED, F.iaedp, CEDS (he/him/his), senior medical advisor at ERC Pathlight, brain rescue supports parents and clinicians to convey a sense of urgency when discussing the young person’s eating disorder and nutritional needs.

“The conversation is not about weight gain but about protecting the brain,” says Dr. Bermudez. “It is in the patient’s best interest to protect their brain, especially in adolescence, a time of much neurobiological development. Patients need to know that the nutritional insult could be significant enough to cause the brain to malfunction and derail brain development.”

The power behind this concept is that even young kids struggling with weight acceptance may not want to jeopardize their brains. Once they realize the potential consequences of their behaviors, they are more likely to become motivated to change it. “Brain rescue becomes a rationale and a justification to see treatment through,” says Dr. Bermudez. “Once they commit to treatment and their nutrition improves, other interventions like therapy and medications will work better, and they will become more capable of identifying and utilizing coping skills.”

NAVIGATING Ambivalence

How providers can turn uncertainty into growth

even years ago, Martha Danielson (she/ her/hers) began seeing signs that her daughter Lydia (she/her/hers), then 14, might be developing an eating disorder. “She was concerned about calories and her weight,” Martha says. “She went from being a very social kid to being very isolated.” Lydia was diagnosed with anorexia soon after.

Martha and her family tried to care for her at home, but Lydia quickly reached a point where she needed a higher level of care. Still, Martha had doubts about agreeing to more intensive treatment. “Lydia was in her sophomore year of high school,” Martha says. “We worried she wouldn’t be able to participate in extracurricular activities.”

These conflicting feelings are known as treatment ambivalence, and they’re quite common among patients and their families and caregivers navigating mental health treatment.

“Ambivalence is like a tug of war,” says Elizabeth Easton, PsyD, CEDS (she/her/ hers), national director of psychotherapy at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight). “Part of them knows they need support and that their current treatment methods aren’t working; yet another part is fearful about what they stand to lose or miss out on while in treatment.”

Why Ambivalence Happens

Feelings of ambivalence are quite common and can happen at multiple points throughout a person’s mental health journey.

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“Ambivalence is a universal response humans experience as they process major changes in their lives,” Dr. Easton says.

Often, patients and caregivers—like Lydia and her family—experience ambivalence due to the time-intensive nature of treatment. “People worry that they have to put their school, work, family and friends on pause,” says Maggie Moore, MA, LMFT (she/her/ hers), national family outreach manager at ERC Pathlight.

Other times, patients struggle with feelings of hopelessness and think that treatment won’t actually help them get better, or even worry about the change that will

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come if it does. Another common barrier is the fear of the unknown. “Concerns about not knowing the clinical team and people you’ll be in treatment with when you’re going through a mental health crisis are understandably one of the most uncomfortable parts of the treatment process,” Dr. Easton says.

And while ambivalence can happen with any mental health disorder, we tend to see it occur in people with eating disorders in particular. “That’s because many patients believe their eating disorder is working for them—that it’s helping them look or feel a certain way—when in reality it’s causing them to lose friendships and sometimes lose jobs,” says Dr. Easton.

For families and caregivers, shame and self-blame are two common causes of ambivalence. “It’s hard for some to acknowledge that they aren’t equipped to support their loved one in the way that person needs to be supported,” Moore says. They might also feel conflicted about how to explain a loved one’s treatment to their extended family and friends, or the time commitment and other logistics involved. It’s helpful to lay out all treatment options from the beginning, including virtual care which can help their loved one build resilience and skills from the comfort of home.

Guiding Patients and Loved Ones

While some providers may view ambivalence as a barrier to care, in reality, the opposite is true. “The points where people get the most stuck in life are the places where the greatest opportunity for growth and healing exists,”

Dr. Easton says. Here are six ways to guide patients and their families and caregivers through ambivalence.

1 Validate patients’ feelings. Ask patients to explain the reasons they feel ambivalent, and listen with equal parts curiosity, compassion and humility. “Understand that the version of themselves that is in crisis feels incredibly vulnerable and has a lot of self-doubt and fear,” says Dr. Easton.

2 Explore their perspective. “Use motivational interviewing to create allegiance and alliance,” Moore says. For example, ask patients what they stand to lose by entering a higher level of care, which can range from daily independence to missing out on special events and family vacations. Then explore what they stand to gain.

3 Stand firm in your recommendation. Reinforce your clinical recommendations, but don’t push patients into treatment. “Walk with your patient, not ahead of them,” Moore says. “Give patients the clinical perspective behind your recommendations and why you believe they can do this.” The sooner they get the treatment they need, the better opportunity they have for long-lasting success in recovery.

4 Meet with families and caregivers separately from patients. Take extra time with families and caregivers, recognizing that they are often a few steps behind their loved one in understanding why a certain level of care is needed. “Ask

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about their fears and give them time and space to ask questions,” Dr. Easton says.

5 Find a program that integrates families and caregivers into treatment. One common reason for ambivalence is the fear that they will be shut out of their loved one’s path forward, or that they will be blamed in some way. Instead, programs like those offered by ERC Pathlight make family and caregivers an integral part of treatment, providing education and family programming so they can learn and heal alongside their loved one.

6 Recommend a support group. Support groups offer a small community where your patients and their families and caregivers can share their mixed feelings in a safe space with peers who have similar experiences, building their confidence and hope for recovery.

When Ambivalence Becomes Resistance

If a patient starts putting up significant barriers to progress—such as ignoring sessions or failing to follow through with treatment plans—they’ve crossed over from ambivalence to resistance. This can create challenges but also opportunities for providers who take the time to explore the reasons behind the resistance.

“When providers are willing to sit in resistance, explore it and not push patients out of it, it can lead patients and caregivers, and even providers, to beautiful places of growth,” Dr. Easton says.

For Martha, navigating through her ambivalence helped her daughter get the treatment she needed. Today, Lydia is thriving, and Martha is glad she sought a higher level of care for her. “No parent is ready to do this, but when a medical or mental health issue comes up, you have to put your trust in the professionals,” Martha says. “Everyone we met at ERC Pathlight eased our fears. They saved Lydia’s life and gave us our daughter back.”

Your patients can access more than 20 free weekly support groups, providing peer support, education and connection as they navigate any mixed feelings in a safe space. To register, visit www.EatingRecovery.com/Support-Groups or www.PathlightBH.com/Support-Groups

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