[DR. CRISTINA CASTAGNINI] Behind The Bite podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift podcast, After the First Marriage podcast and Eating Recovery Academy over at practiceofthepractice.com/network. Welcome to Behind The Bite podcast. This podcast is about the real-life struggles women face with food, body image and weight. We're here to help you inspire and create better healthier lives. Welcome. Hello, hello everyone. Welcome to the show. I often get asked for information about, or referrals to eating disorder treatment centers by patients or loved ones of patients. While for the most part, eating disorder treatment centers offer very similar treatments, they're really not all exactly the same. While I do not endorse any one treatment center in particular, as I think it's really up to each individual person to feel comfortable finding and choosing one that they feel is the best fit for them, I do think it's important to know more about higher levels of care, just in general and to know more about what may make one treatment center different from another. To me, the more information you have, the better, especially if you ever find yourself in a situation where you may be searching for a treatment center and feel lost, trying to find somewhere that's a good fit for you. With that being said, our guest is here today to touch on a few topics like medication and the treatment of eating disorders and the particular challenges faced by the LGBTQI+ community but she's also here to tell us about how treatment at the center she works at is unique and different from other eating disorder treatment centers. As Chief Medical Officer at Alsana, Margherita Mascolo leads the medical component of Alsana's adaptive care model. She has over 10 years of hands-on experience and extensive knowledge and after completing her undergraduate work at the University of St. Thomas in Houston, Texas, she earned her medical degree at the University of Texas Health Science Center. Her residency was completed in internal medicine at the University of Colorado in Denver. [DR. CRISTINA] She's board certified in internal medicine, has published multiple peer reviewed articles on the medical complications of eating disorders, travels nationally and internationally to speak on these complications and has earned her Certified Eating Disorder Specialist, the EDS certification. Dr. Mascolo, welcome to the show. [DR. MARGHERITA MASCOLO] Thank you. Thank you so much for having me. [DR. CRISTINA] Well, I'm excited. I haven't had anybody on here to discuss Alsana in particular and I know it's a little bit of a different treatment center, well, not different in the sense of treatment, but it offers something a little bit different than other treatment centers. So I'm wondering if maybe you could discuss that a little bit so people know like, okay, when I'm looking for a treatment center, why would I choose Alsana over the other ones? [DR. MARGHERITA MASCOLO] Oh, thank, yes, I'd be happy to chat about that. So at Alsana we have a, well, we've coined as the adopted care model to care for the clients that come to seek treatment with us. It's a little bit different than the traditional sort of pyramid in eating disorder treatment of clinical medical and nutrition. We've expanded that to add two more dimensions to our treatment model, one is the movement dimension, which is a very prescriptive movement dimension that's based on data and we track outcomes. It's not sort of just yoga therapy three times a week, but it progresses as the client progresses through treatment. The other dimension is our relational dimension, which is, the dimension is a little bit more of our touchy feel soft dimension that seeks to really repair relationships mainly to self and then to sort of your inner circle. We do that by focusing on compassion focused therapy as sort of our clinical foundation. I've learned this from our chief clinical officer. There's three flows of compassion and patients that struggle with eating disorders have, are really good at being compassionate towards others, but they really struggle with receiving compassion from others and being self-compassionate. So we're very intentional in our treatment at restoring that compassion and allowing them to receive compassion and we actually track those scores as well from admission to step down and discharge. That's how Alsana is a little bit different. If anyone's interested at our, in our website, alsana.com, there's all kinds of information on our adaptive care model and how it came about. We serve patients that are 18 and older and all genders. [DR. CRISTINA] Okay, so yes, let's talk about that because I know people might ask that, okay, so when you say all genders, if somebody were to go and say like a residential or a higher level of care how do you serve all genders? [DR. MASCOLO] We're very respectful in the language that we use and we room our clients based on the gender with which they identify, so to be as respectful and honoring their chosen gender. That's how we room the clients. We don't, I know there's some centers that sort of have different groups and different houses for the LGBTQ+ population. We don't believe in that. We believe in integration and respect for anyone's life choices. So when they come to Alsana we treat them just like everyone else for their eating disorders. We're very intentional about tracking outcomes and being respectful and making sure that the clients have really experienced that. We actually have perception of care scores that we ask on admission and on step-down and discharge to make sure that the environment for them is affirming and respectful. [DR. CRISTINA] So let's say I am somebody looking for a treatment facility and I'm trying to figure out what it would look like if I were to enter, say, like one of your programs, like how many people typically are in a higher level of care and like what is the environment look like in terms of who I would be rooming with and all of that because I know people ask these kinds of questions. [DR. MASCOLO] Yes, no, of course. So we have facilities of varying sizes. The majority of our facilities are fairly small. In California we have four, six-bed houses and a 12-bed house. Missouri, we have a 10-bed house, one of them is 20 beds, sort of depends. The clients can really get different experiences, so they'll get the same awesome experience wherever they go but if they thrive in a larger milieu, we direct them to one of our larger programs. Otherwise, we direct them to our smaller facilities. Our locations are based in homes, so we have beautiful houses in Monterey in California, bed and breakfast. That's just stunning. Our Westlake facilities are beautiful and so they're homes. They're usually, most of our facilities have two people per bedroom with a shared bathroom. A lot of the assignments for rooms are based on really the order in which the clients come. So we try and honor requests that they have them, but really it's whoever's coming in, we see where the bed is available and we place them there. All the homes have outdoor spaces. A lot of our meals are done outside. There's a lot of outdoor activities and outdoor time in nature, whether that's a walk in the beach or at a national park in St. Louis. Birmingham is a little more of an urban setting so a little bit different. So there's really sort of room for whatever the client needs and wants to experience. [DR. CRISTINA] Okay, so it sounds like you really try to tailor it to whoever's coming in and try to make them in an environment --- [DR. MASCOLO] That's right. In part sometimes we're sort of bound by what insurance companies will cover. Some of them will say only California, only Missouri or only Alabama. So then we certainly, we have to work within that, those confinements [DR. CRISTINA] It's interesting, so as like an outpatient clinician myself, I found it during at least pandemic, there was like long wait lists for higher level of care treatment. Did that happen at Alsana as well? What did you find? [DR. MASCOLO] So the pandemic hit and I was like, oh man, I'm going to be out of a job. Who's going to come to who's going to fly to treatment? In a very, very sad way, we just saw our business boom. I mean, the need had never been greater. We really saw people struggling with mental health really sort of take a turn and struggle even more and really have no access to care. So we really spent the beginning of the pandemic trying to build more capacity because our wait list were getting so long. In the middle of the pandemic, we were actually lucky enough to be able to launch a truly centralized virtual PHP and IOP level of care. Because while we, really, we did several different things. So we really doubled down on the safety of our brick and mortar programs. We felt very strongly that these patients needed care and deserved to be, especially at higher levels of care to be in brick and mortar. So we put a ton of Covid safety protocols and mechanisms in place. We did that for residential PHP and IOP, but we also recognize it with the pandemic and the sort of fear of travel and fear of being around other people that there was a need for virtual programming. With all the executive orders that were in place, we were able to launch a virtual PHP IOP. Just like everything we do, we've been tracking outcomes and it's just been really amazing to watch. Clients do really well in the virtual setting. What we've learned is that, especially the clients that have binging as part of their disease do really well in the virtual space. Maybe something about cooking in their own kitchen and going to their own grocery store and has been really therapeutic for them. That's how we sort of dealt with the pandemic and the need for more beds. We opened four new facilities during the pandemic. [DR. CRISTINA] Oh, wow. I guess that's actually a good next question for anyone listening, is there a specific eating disorder that is for each facility that's like more, or do you, does it matter what the diagnosis is, because I know that some treatment centers specialize more in binge eating disorder or bulimia nervosa. How does Alsana work? [DR. MASCOLO] Yes, that's a great question. So we treat all eating disorders at all the facilities. We don't sort of assign based on the type of eating disorder. We also treat all body shapes and sizes and all our facilities because the sort of foundation of a eating disorder is the behavior as anorexic can come in many different body shapes and sizes. So we respect that and honor that, and we treat it at every facility. [DR. CRISTINA] Now, I know you and I have talked a little bit before and something I've never had discussed on the podcast is the LGBTQ+ community and I know that's a population that Alsana tends to cater to a little bit more and has as a population. So I'm wondering for somebody who's looking for treatment that's more sensitive to that population, what does Alsana offer? [DR. MASCOLO] That's a good question. About 30% to 35% of our population identifies as LGBTQ+. As we sort of mentioned before, we accept them at all our facilities, at all levels of care. We assign genders based on the gender with which they identify and we really provide affirming respectful care. For example, a transgender client, there can be a spectrum of sort of treatments that they can be undergoing right from dressing in the gender with which they identify all the way to sort of the surgery, top surgery, bottom surgery hormones. We respect anywhere where they are on the spectrum and treat them accordingly. So if someone comes in and they're not on hormones, we don't treat them with hormones. If they are, we continue the care and we work really closely with their outpatient, either endocrinologist or family practitioner, whoever's prescribing their hormones to make sure that their care is continued and not interrupted. We work, our dietary, our nutrition dimension works really closely to make sure that their weight goals are in alignment with the gender with which they identify and our movement dimension of course pays attention to muscle mass and sort of the needs of the body, the fuel that it needs for the movement. I mean, at the basis of everything is compassion focused therapy. So we use compassion in the care of our LGBTQ+ population. [DR. CRISTINA] Now, are there specific, I guess are there differences in terms of what you've found that that population faces in general that maybe people are not, that they deal with in treatment that maybe is different? I haven't really talked to another clinician about that, like, are there specific things that maybe people wouldn't know, like, oh, this is a very big issue that they're facing in terms of discrimination or in terms of stressor or trigger? [DR. MASCOLO] Yes, for sure. So couple different things one, there's a lot of discrimination in in that population. There's a lot of sort of fear of, and also experiences of adverse consequences, a lot of violence and bullying toward that population, unfortunately. What is at the crux of, at least in my dimension, my medical dimension, I'm an internist by trade, is that these clients have really a difficult time assessing appropriate treatment and appropriate care for them. As physicians we're not necessarily trained in the needs of the LGBTQI+ population, especially when it comes to transgender care. So even things like the questionnaire at a doctor's office, what is your gender male, it's very binary. You can only pick male or female. Restrooms at a lot of physicians' offices or anywhere they go are either male or female. So these are all things that unfortunately we don't necessarily think about, but they can be very oppressing and be very difficult for this population. Certainly the, even the physical exam, the appropriate exam for the gender with which they identify. The difficult conversation. If someone identifies as female, do they have, do they still have male parts that need to have cancer screening? Do we need to test for testicular cancer? Those kinds of things can be really difficult for this population. So in the sort of therapeutic piece of this, our therapists need to be mindful of what this population's everyday life looks like. A couple sort of, I mean, really sad statistics is that these patients have really high mortality rates by suicide. So we need to be very mindful of that. I mean, we have suicide screening and assessment for all of our clients, but to especially have a little bit of a different light, a little bit of a different acuity for the LGBTQ+ population. There's a lot of eating disorders in this population. The reports sort of vary from anywhere between like 30% to about 55% of LGBTQ+ youth reported having an eating disorder diagnosis. So very, very, there's a lot of crossover between eating disorders and that population. About, this is one site in particular, quoted that almost up to 60% of youth that identified as LGBTQ+ and had an eating disorder had contemplated suicide. So it's certainly something. We know that in general with clients that have eating disorders, so first of all, eating disorder has the second highest mortality of any psychiatric disorder second to the opioid epidemic. They die by suicide and medical complications that are unrecognized and untreated. So we are clinically, we very aware of the suicide piece and medically, of course, very aware of the medical complications and we aggressively screen for them and treat them. [DR. CRISTINA] So in that light, so does Alsana also treat the comorbid diagnoses of if there's major depressive disorder, anxiety? Like how does that treatment look? [DR. MASCOLO] Yes, no, absolutely. So while truly the treatment for eating disorders is nutrition therapy, especially group therapy, that's where they have, they do the most sort of therapeutic work, it's really important for these clients to have their comorbidities treated and addressed. Most of the comorbidities, there's a lot of medical complications, but as far as the psychiatric comorbidities, there's so of course, depression, anxiety, mood disorders, and unless we treat those, the patients are really, it's really hard for them to progress through treatment because many times their anxiety can be debilitating right to the point where they are unable to complete their meal, they're unable to participate in group. So our psychiatrists are trained on that and very, very aware of the need for in this case it's medication in order to treat the comorbidities. [DR. CRISTINA] I could imagine somebody listening, going medication, wait a minute, is that necessary? Is that a much-needed part of the treatment? Because I know some people who I work though, I don't want to take medication? Is that a must? [DR. MASCOLO] So it's not a must. What I like to tell our clients is that it's part of our tool belt of interventions that we use in order to help them. Does it mean that they need to be on this medication forever? No. Many times a starved brain can be depressed, can be anxious, can have mood disorders. So some of that is a little bit difficult to tease out, but certainly what I like to tell them is that if they're able to have some help during this really difficult time in their life, so these clients come into care, maybe they're flying across the country to come to our facility, they're away from home, from their friends, from their family, from their support, we have cell phone policy and all kinds of stuff. It's such a different environment. Any one part of that can be so stressful and so triggering. We're asking them to sort of tackle all that at once and deal with their eating disorder. If we can help their anxiety and their depression while they're in treatment for them to be able to have that sort of mental calmness and clarity in order to engage in what we have to offer then I like to have them use the medication to help them. Again, not long-term. Once we have treated their eating disorder and have their engagement in treatment, those medicines can be tapered off. They're not lifelong necessarily. [DR. CRISTINA] I mean, we could have a whole podcast on medication, I think [DR. MASCOLO] Right, yes. [DR. CRISTINA] So I mean, maybe I'll be back to just talk about that because I think there's a lot of questions people have about that. [DR. MASCOLO] Well, there's a lot of fear. A lot of these medications have weight gain as a side effect so how do you tell somebody who has body dysmorphia is a low body weight and is struggling with getting the calories needed, that you're going to give them a medication that makes them gain weight? Those are tough conversations that our psychiatrists and our clinical team face almost on a daily basis. The fear is real and it needs to be recognized and addressed. [DR. CRISTINA] I think that's a fear. At least, I see when I put out posts on social media, people have that fear of even entering treatment of, oh, well, if I go into treatment, that's going to be what happens, is I'm going, my body's going to shift, my body's going to change. I don't want to. If I can get over my eating disorder and not have my body change, I'll sign me up. But if I have to go in and my body's going to change no way. That's too scary for me. So even if there's no medication offered, I think that's a big fear. [DR. MASCOLO] Oh, absolutely. Unfortunately, we can't have eating disorder treatment without their body changing. So first of all, we focus on behavior changes because this is what it's about and this is what will ultimately keep these clients in recovery. But the body will change. So it's important for us to, and the way we deal with it, so we deal it with it, every sort of, every dimension deals with the body changing. Medically, we sort of talk about the elephant in the room, like, hey, you're going to start to eat a healthy, balanced diet and your body will change, but it's okay because right now your body is starved and deficient in nutrients and taking calcium from your bones and debilitating your bones and your GI tract is completely shut down because it's trying to absorb everything that it possibly can. So right now, your body is not healthy. What we want to do is change it to be healthy and part of that requires just yes, there's a change to your body [DR. CRISTINA] Right. [DR. MASCOLO] So we talk about health, not necessarily, we don't focus on a number, a number on the scale. Same thing for our clients in larger bodies that have binge eating disorder we work on the behaviors. When the binges stop, sometimes the the clients will lose weight. It's certainly not an outcome we're shooting for, we're working on their behaviors, but it does result in changes to their body. [DR. CRISTINA] That's the interesting part, as I always hear people say, well, that's the goal, is I want to stop binging because I think like that's going to happen. Sometimes it doesn't. I think that's what their goal is, it's ultimately still a diet mentality so that people go, yes but it's like, well, that can't be the focus, that can't be the goal of treatment, because that might not happen. [DR. MASCOLO] Exactly. It never is for us. We never focus on the weight number piece as you know, I mean, BMI and ideal body weight are not great measurements of the health of a body. We can have a whole other podcast on that. Exactly. So in women, you shoot for when menses resume, that's when the body tells you that, oh, okay, I'm at a good point. So there's a lot of factors that are involved in the nutrition component and how the body changes and the conversations that we have around that. [DR. CRISTINA] So we derailed a little bit from the specific concerns and struggles of I guess the LGBTQ+ community because I do want to address that a little bit more just in case, if somebody's listening specifically to get more information about that like maybe saying, "Hey maybe I'm more interested in going to Alsana than somewhere else. They seem a little bit more aware and sensitive." Or maybe somebody is just wanting to know, is there language that I need to be more sensitive about? Or are there issues I need to be more sensitive about towards somebody who's got an eating disorder, who's in that group that maybe I don't have awareness about? Is there anything you can say to the audience that maybe people wouldn't really have awareness of that you do because you work with that population? [DR. MASCOLO] A couple things I would say, be very sensitive to the fact that this is a marginalized population. It's a population that's been, that is discriminated against and that has a lot of underlying eating disorders that unfortunately many times are not recognized and not treated. So I thin, for someone who is not LGBTQI, I would say when you do encounter someone who is to think about that in everything that you say and do, and to be very respectful of where they are in their journey and what they identify with. I think it's always, I think it's super important to let the client be the driver. So ask them how would you like to be addressed? What is your name? How do you like to be, how would you like to be addressed? Don't make assumptions based on how they look or how they dress. It goes back to sort of like the golden rule, the ABCs. That would be my biggest piece of advice is to just be inquisitive and ask the person with whom you're having the conversation, what their preferred gender is, how they like to be addressed, what their pronouns are, and then just remember those and address them in that way. Be particularly sensitive to the fact that their day-to-day life is very different from a non LGBTQI person who like if you're a female, that if you identify as being a female, you walked into a girl's bathroom anywhere you go, you can find that, you've never had to sort of struggle with deciding where to go. [DR. CRISTINA] So any clinicians that might be listening, is there anything like an outpatient clinician or is there anything that maybe they could do differently in their practice? [DR. MASCOLO] Yes, I would say the biggest thing is to be aware of the high percentage of eating disorders in this population and to screen them, screen the signs that they have for the presence of an eating disorder. Because having an eating disorder, being in the LGBTQI population and having an eating disorder, the mortality can be really a lot higher because the suicide and the complications. So to me it's to really do a good job of building rapport and asking them the eating disorder questions, the questionnaire is five questions and it's fairly easy to do and to identify eating disorder early and to treat it is really the best shot at having a recovered life. [DR. CRISTINA] So in your opinion, do you think that the higher risk for suicide is because they experienced life much differently and feel that discrimination? [DR. MASCOLO] I think so. I think A, having any disorder alone, and then B the discrimination, the bullying, the teasing, we know that all those risk factors for the development of a eating disorder. So I definitely think it's a combination of things. To not be able to live as your true self. I mean, the psychological impact that that has the struggle with having to live in a body you don't identify with or mentally that's very heavy. [DR. CRISTINA] In a very unforgiving society on top of that. [DR. MASCOLO] Exactly, exactly, in a society that's very binary, it's zero or one and male, female, that's it. [DR. CRISTINA] Well that, I mean, I was just thinking that must be really interesting to go to a very supportive environment such as Alsana and get treatment and feel very supported and get that compassion. Then how do you give them the skills and the tools for when they discharge and leave Alsana to manage like the world that's out there? [DR. MASCOLO] As they make progress through treatment, we have experientials for them. So let's go outside and what's it like to make a grocery list and go to the grocery store? How do you sit down and order from a menu at a restaurant? We have clients, I think at least once a week have client creation meals, how do you sort of create your own meal and serve it to other people? It can be, the experientials can also differ based on what the need is. So maybe how do you go to a mall and shop for size appropriate clothing? That can be very intimidating or challenging. Go to a picnic with friends, sort of teaching them, we teach through experientials and sort of living those situations in an environment that's still safe and afterwards they can really sort of have processing time around it. [DR. CRISTINA] Then specifically for the LGBTQI community, like Alsana seems very supportive, so for those patients that are getting discharged that are going to go back out into a society where there's not the bathrooms and the support and maybe even family members or friends who are maybe saying critical negative things and they're not feeling like all the support that Alsana provided them, how do you help them get back into maybe a toxic environment that maybe was the impetus for the eating disorder or the depression? [DR. MASCOLO] Yes, no, that's definitely tough. So one through compassion, so all those things outside are not about the actual client themselves. It's about the other person that, I mean unfortunately things that are said are very hurtful and spiteful, but we teach them of course to have self-compassion. And we really empower our clients to have a voice, make your opinion known, tell people who you are, how you prefer to be addressed, and whatever they sort of say or think about you, it's okay. Those are their thoughts. Those are not your thoughts, and they shouldn't govern your sort of day-to-day life. Now those are really difficult things to, I mean, it takes a while for them to really be able to be advocates for themselves, but fundamentally that's what we teach them to have compassion and to be advocates for themselves for their needs and their wants and for who they are. [DR. CRISTINA] It's really unfortunate we can't just change society and their world and make it all nice and supportive, like in the contained environment you provide for them. [DR. MASCOLO] I know, I know. [DR. CRISTINA] So giving skills and coping mechanisms and I guess insight and awareness too. [DR. MASCOLO] For sure, for sure. Insight into how they feel, like how does someone saying X thanks to you make you feel? We do a lot of exploring that and sort of processing through that, because you're right, a lot of their the relationships that they have outside of treatment are triggering. They are toxic, they're not supportive. And I should say another way that we support them is that we actually do have, we have a really strong family program and we bring families or significant others or whoever their support is into treatment and we'll do sessions with them to make sure that the family or the support system is able to like, understand what these clients are struggling with and really to receive them back in their care when they're done with treatment. [DR. CRISTINA] Like that bridge. [DR. MASCOLO] Yes, exactly, exactly. [DR. CRISTINA] Well, I mean, I always love when somebody comes on and gives information about options for treatment, because I think people feel deer in headlights, especially if they get the news from an outpatient therapist like myself. Like, okay, I think you need a higher level of care, and that's this daunting. What does that mean? What do I look like? Or even if I suggest somewhere, they're like, oh, it's overwhelming. So just to have more information and know somebody like yourself they've heard you and it's like, it's more information. It's more of like, oh, there's a place that this makes more sense, or I know more about this place and I feel more comfortable calling. So I really appreciate you coming on and talking more about what you offer. You have a lot of facilities and got a lot of support and a lot of, do a lot of great work. So I appreciate you [DR. MASCOLO] Thank you. I appreciate you. I appreciate you having us. I feel very passionate about eating disorders and helping people that have eating disorders. So as much education as we can provide the better for me. [DR. CRISTINA] Well, and I just as a clinician too, I appreciate that you as medical doctors are trying to get as much of the correct information out there too, because I know I've had done lots of podcasts and I talked to you about it too, like the medical field just is lacking so much of the correct information. So just personally, I thank you for the work you're doing and trying to get all of that out there too. So thank you for that. [DR. MASCOLO] Thank you. Thank you. I appreciate you saying that. [DR. CRISTINA] Is there any final last words before we end? [DR. MASCOLO] No, I would say anyone that has an eating disorder or is struggling with disordered eating, I think reach out. There's a lot of help out there. I mean, whether it's Alsana or another center, of course, I encourage you to call Alsana because if we're not the right level of care, if we're not the right treatment for you, we make referrals to all kinds of other programs. A lot of treatment centers do that too. So I would always encourage to just call and get your questions answered and do an assessment to see if free treatment is the right thing for you and if you're in need for it. The other thing that I would say is that just like any other medical condition, the sooner the diagnosis is made and treated, the better the outcome, the better the chance at having a recovered life for not thinking about eating disorders anymore. [DR. CRISTINA] All right. I know you gave the website earlier, but could you repeat it again and say somebody does want to find out more about Alsana [DR. MASCOLO] Absolutely. It's www.alsana.com. There's our admission line, there's information about our adoptive care model, our beautiful facilities, our staff and there's emails, phone numbers, all kinds of ways to get ahold of us. [DR. CRISTINA] Fantastic. [DR. MASCOLO] We even have an app actually on the website that sort of screens for eating disorders. [DR. CRISTINA] Oh, good. Well, that's very helpful, I think, too. People always have questions about that. Well, thank you again so much. Really appreciate you and all the work you're doing. [DR. MASCOLO] Thank you for your time. It was wonderful to hear out here. [DR. CRISTINA] This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.