Dr. Jack Krasuski:  Dear colleagues, hi.  It’s Dr. Jack Krasuski.  I’m here this morning with Dr. Jennifer Derenne.  Dr. Derenne, thank you so much for joining us at the Oasis Child and Adolescent Psychology Conference.  We appreciate you traveling all the way here to present your topic which is eating disorders.  Could you give us whatever you feel is the biggest highlight of what’s going on with eating disorders?  What would you like to share with our fellow clinicians that you think would be the most important message for them, a practical, actionable message you would like to send them?

Dr. Jennifer Derenne:  Thank you so much for having me.  It’s a pleasure to be here.  I think probably the biggest take home message when it comes to treating eating disorders is that re-nourishment as food is probably the most important intervention that we can do for these patients, and if we don’t focus on that first then we’re not going to be able to get at the concerns about self-esteem, the anxiety, all of the underlying issues that oftentimes kids and their parent come to treatment worried about.  While it’s tempting to focus on those things first in treatment, we really need to focus on nutrition first.

Dr. Jack Krasuski:  Yes.  You had in all caps:  FOOD IS THE MEDICINE.  I do appreciate that.  You mention it’s tempting to focus on other things.  It’s not just that we as clinicians are tempted.  Instead, our patients like to tempt us, to really distract us.  Sure, but before we get to that, let me tell you what’s going on with my boyfriend or this or that.  It’s like, anything but the food, where we have to keep bringing it back because food is the medicine.

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Focus on the Nutrition, Not the Drama

Dr. Jennifer Derenne:  Exactly.  Exactly.  I always just tell people that they have to really keep their eye on the prize, that if we don’t focus on the nutrition, we’re not going to get this kid better.  Definitely, we will use medicines if we need to in the service of treating the comorbid conditions, but really the discussions about the boyfriend and the drama with friends and the worries about grades, that probably needs to be put off to a later date.  I always say that these are the life-threatening issues that we need to focus on right now.

Dr. Jack Krasuski:  Yea.  I’m glad you mentioned that because my analogy is to DBT where it’s very clear, it’s explicitly stated in the treatment that you focus on the life-threatening, the suicidal symptoms, the self-induced behaviors first, and nothing comes until that is addressed, and every session that’s what you start off with.  I think there’s a reason to do that because it’s easy for both the clinician and the patient often to just not want to have those tough talks, and yet, without those tough talks, things don’t really change.

Dr. Jennifer Derenne:  Yea.  I know.  Absolutely.  Yea.  I think that’s a great analogy actually.

Dr. Jack Krasuski:  Also, following up on this idea about food as medicine, when kids are so disordered in their eating behaviors or people with anorexia particularly who are in a semi-starvation state, it just changes, it’s sort of like they’re in some different mindset.  We can’t just accept their mindset.  It’s like it’s somehow almost delusional in some way.  It’s coming from a different place.  Until they get the adequate nutrition, you can’t bring them back into having a more flexible and rational view of themselves in the world.

Dr. Jennifer Derenne:  Right.

Dr. Jack Krasuski:  Could you speak to that part?

“Driving Under the Influence of Anorexia”

Dr. Jennifer Derenne:  Yea.  Absolutely.  I’ve had parents say that they feel like their child has been taken over by an alien of sorts.  I usually talk about it as you’re kind of driving under the influence of anorexia right now, and until we allow you to sober up and get that out of the way, we’re not going to be able to make the progress that we need to, so I agree with that 100%.  I think kids often really resist that because they will say, no, this is me, and you’re not honoring that.

Dr. Jack Krasuski:  They’re going to use our therapeutic language against us.

Dr. Jennifer Derenne:  Exactly.  Exactly.  But I do think it really helps to externalize the illness and to really help the parents see that until their child is able to make good decisions and be more independent, they really need the parents to be involved and to help out with the re-nourishment process.

Dr. Jack Krasuski:  Could you say more on the concept of externalizing the illness?  What do you mean by that?

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An ‘External Process’ That is Taking Over

Dr. Jennifer Derenne:  I think it is really helpful for people to conceptualize eating disorders, not as something that’s voluntary or an attempt to just be skinny or be vain but really that this is an external process that is taking over.  We have the patient, themselves, and we have the illness, and there are periods of time where they overlap.  When that happens, it can be really difficult to get through to them because they’re so stuck in the process, but the healthy self is there.  We just need to work on separating the eating disorder from that.  I think it really does help to view it as more an external process, rather than something in the patient, and I think it helps families to think about it in that way too.

Dr. Jack Krasuski:  I see.  Where they’re coming from, and that’s not their true self or an expression of their true self, it’s really, like you say, under the influence of anorexia.  I love that analogy.  An analogy I sometimes use is it’s like you’re in a cult, and some of them actually kind of are, like an online cult, anime culture.

Dr. Jennifer Derenne:  Exactly.

Dr. Jack Krasuski:  I think a lot of clinicians underestimate how people with eating disorders often are so alienated from their normal peer group and are into some online, very pathological groups.  Like you mention, some of these self-help books written by people, it actually triggers them.  It’s like a learning manual.  Some of the stuff you look online, it’s so pathological.  It’s creepy.

Dr. Jennifer Derenne:  Yea.  It’s really disturbing.  I think that a lot of the internet browsers and organizations like Google and Facebook and Instagram have really done a lot to try to curb the proliferation of these sorts of things.  They make it so they can disable certain hashtags so that people can’t use them to create these online groups that are not useful, but there’s only so much they can do.  People will just change the spelling or put a symbol in and then they can’t filter . . .

Dr. Jack Krasuski:  It’s a battle that’s never won.

Eating Disorders and Online Behavior

Dr. Jennifer Derenne:  Yea.  They can’t filter it out anymore.  I think this really speaks to the ways in which parents can be useful when talking with their kids about their online internet consumption and social media use.  I’m not advocating that patients not have access to their phones.  I do advocate though for parents to be curious with their kids about what sorts of things they’re looking at online and if they find it helpful or not.

If a parent says, I don’t think it’s useful for you to follow this Instagram blogger because she’s really focused on clean eating and over exercise, the kid is going to say, well, I don’t really care.  But if the parent says, hey, I noticed that you follow this blogger, can you tell what appeals about it to you?  Can you tell me what it’s like to see her posts each day?  I was thinking about the fact that you’ve been struggling with an eating disorder.  How do you think this influences your recovery?  Inviting the child into the conversation I think is just much more effective and I think helps them to learn how to live in today’s society using the electronics and the equipment that we all have available to us.

Motivational Interviewing Technique

Dr. Jack Krasuski:  Thank you so much for sharing that.  Earlier this morning I had a conversation with Dr. Sanchez, and we were talking about cannabis.  She was talking about motivational interviewing techniques and exactly what you said.  It’s that same approach.  You can’t be lecturing at the teenager.  They’ve heard it all before.  Here’s another adult.  Okay.  Tell me when you’re done.  When I see your mouth stop moving, then I’ll know to pay attention again.  But I think that’s a really beautiful way.  It’s really engaging them and starting with the positive.  What is it that you find useful?  What is engaging about this?  Tell me about it.  What effect do you think this has on your health, on your eating?  What’s the impact on you?  Thank you for that.

Dr. Jennifer Derenne:  Of course.

Dr. Jack Krasuski:  Dr. Derenne, thank you again so much for doing your presentation and being here with us and then sharing these few words of wisdom in these few minutes that we’ve just spoken.  Thank you again.

Dr. Jennifer Derenne:  Thank you so much for having me.  It’s been a pleasure.

Dr. Jack Krasuski:  Alright, doctors, see you later.  Signing off.