Eating disorders come in different types and forms. Individuals with eating disorders can experience different symptoms even if they have the same disorder. As such, various treatment programs are often used to help patients. Toronto General Hospital (part of the University Health Network) offers a referral-based Eating Disorder Program to help adults diagnosed with an eating disorder, including anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorders. We interviewed Tracie Burke, a registered dietitian and registered psychotherapist in the Eating Disorder Program to learn more about the program, her role, and her perspective on eating disorders.
What are some of the different programs offered at the Eating Disorder Program at Toronto General Hospital?
The services our team provides include in-patient, day treatment, and relapse prevention programs.
In the in-patient treatment program, people are admitted to the hospital. They are likely to be medically unstable and require acute medical attention, as they’re going through the re-feeding process [re-introduction of food after malnourishment or starvation may cause sudden shifts in the electrolytes in the body, which can result in fatal outcomes1]. For some individuals, this could be the first point of entry into a longer series of recovery steps. For some, it may be meeting a specific and/or time sensitive goal. For instance, a patient may want to get off laxatives in 3 weeks. These individuals may not necessarily be thinking about larger recovery goals, but one small piece they might need is medical management.
The length of the day treatment program varies between patients based on their needs. Patients will have full weeks’ worth of different programs they attend.
The relapse prevention program focuses on preventing relapses. Here, we have patients who have completed the day treatment program, reached their goals, and showed a spirit of recovery.
What are some of the key counselling methods in the day program?
We offer group therapy programs that are evidence-based for the treatment of eating disorders and are specific to different aspects of counselling.
We have groups that are focused on skill building for dialectical behaviour therapy (DBT)-skills for emotion regulation and incorporation of mindfulness. These skills can help individuals give up their eating disorder symptoms. We have groups that are more focused on cognitive behaviour therapy (CBT). One of the key aspects is using ‘thought records’ to challenge thoughts that are associated with behaviours. We try to get individuals to move their thinking away from rigid and unhelpful to more neutral and helpful.
We have structured meals and snacks, which is a key reason for some people to come into our program. We have meal groups to help them figure out what they’re going to eat, how to incorporate foods that they may have either avoided in the past or only had during symptom-related to eating disorder. We try to provide an opportunity to get some food exposure and break down some of the negative associations they might have around particular foods.
We work on other skill practices and re- framing perspectives. We do a lot of ‘building a life’ or thinking about self-esteem. This could mean starting to incorporate new activities or re-incorporate old activities into people’s lives. We have groups that are focused on body image–try to minimize behaviours that maintain an unhealthy focus on the body as people try to move away from thinking about self-esteem as body image only.
What are your primary roles as a dietitian and a psychotherapist within your team?
As a dietitian, I’m responsible for delivering the nutrition care process. I would complete a nutrition assessment [diagnosis of nutrition problems using various nutritional indicators including medical, nutrition, and medication histories2], and provide support throughout the program. Oftentimes, the goal is to normalize their eating. This has many components and can look different for everyone–it could be having three meals a day, eating enough food, or gaining weight. We work on building healthy eating behaviours. We take them out for meals to expose them to eating out in public, learning how to portion foods, having varieties of foods, and going grocery shopping. We do a lot of psycho-education, where we teach what ‘normal’ nutrition is. We try to help dispel some of the myths that individuals may have picked up in their eating disorder journey and equip them with more neutral evidence.
As a psychotherapist, I use psychotherapeutic techniques from motivational interviewing, CBT and DBT to develop a therapeutic relationship with clients that supports and maintains change. There’s often ambivalence that comes with making behavioural changes to eating behaviours and weight. It’s not uncommon for patients to break down when they’re trying to make changes to their eating. As a psychotherapist, I can assist them in getting through these tough moments and place their long-term goals in perspective.
What are some tips you have for those who may not be familiar with signs and symptoms of eating disorders?
People can be struggling even if it seems like they’re not. Generally, people who have eating disorders, also have other co- morbidities like depression, anxiety, history of trauma, or addictions. Eating is often a symptom of other issues they are going through.
Recovery is not as simple as “just eat.” Sometimes when your loved one has an eating disorder, it can be hard to understand the complexity of the illness. We may simplify it and say “just eat,” but it is hard to make the change. If we think about the messages that we get in our culture around thin bodies and good and bad foods, there’s a lot of evidence to support eating disorder behaviours if someone wants to find it. Recovery could often feel like ‘swimming upstream,’ going against the current. This can be really hard to do on their own, so group therapy could be the best approach to get the support individuals need.
There’s also an ownership aspect to the treatment. When we see people that come into treatment for someone else, it generally doesn’t work. Individuals may agree, but they are not really sold on the idea, because they are not ready. A big piece of recovery is being ready to make a change, especially because there will be a loss. They are going to be giving up something that had served as a function in their life whether to suppress depression or anxiety, or clear out traumatic memories. Losing eating disorder behaviours can have consequences, so individuals have to be ready and willing in order for changes to stick.
We used to think of eating disorders as more of an acute illness, but more and more, it feels like a chronic illness. Some people can come in to the program to have one dose of treatment, continue to maintain the changes, and live a life without their eating disorder. For others, they may have to come and do one piece, then come back to do another 7 piece. That is not a failure; it’s part of a longer lifetime journey of recovery. It’s as if you have a chronic illness–your symptoms might flare up and need more support to manage. I think dispelling some of the myths that people may have about eating disorders can be helpful in understanding.
1. Solomon SM, Kirby DF. The refeeding syndrome: a review. Journal of Parenteral and Enteral Nutrition. 1990 Jan;14(1):90-7.
2. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors and Clinical Practice Committee. Definition of terms, style, and conventions used in A.S.P.E.N. Board of Directors– approved documents. American Society for Parenteral and Enteral Nutrition. Published July, 2010.
Edited by Celinia Liu & Emily Deibert