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.