MEET DR. MICHAEL WETTERDr. Michael Wetter, Psy.D., is a clinical psychologist with over 25 years of experience, who has a private practice in Los Angeles and is the Director of Psychology at UCLA Medical Center, Division of Adolescent & Young Adult Medicine. He is an Adjunct Professor of Psychology at Pepperdine University and has served in leadership positions at nationally ranked hospitals including Kaiser Permenante and Cedars Sinai Medical Center. Dr. Wetter is an award-winning author of books including “Earn It: What to do when your kid needs an entitlement intervention” and “What Went Right: Reframe your thinking for a happier now". You can learn more about Dr. Wetter by visiting his website at www.drwetter.com. Connect on Twitter or LinkedIn. Contact his practice at 818-835-7707 or email him at email@example.com.
IN THIS PODCAST
- Restrictive treatment
- Residential treatment
- Partial hospital program treatment
- Intensive and traditional out-patient programming
- Different treatment modalities
Restrictive treatmentThere are multiple levels of intervention available for people who need treatment through an eating disorder. First, what the doctor needs to understand is how the disorder is manifesting itself in the patient. Common types of eating disorders are:
- Anorexia nervosa and its subtypes,
- Bulimia nervosa and the degrees of bulimia
- Avoidant restrictive eating intake disorder.
What will really determine the disposition and effective recommendation is where along the line of continuum of the particular disorder does the patient fall. (Dr. Michael Wetter)When medical staff are concerned about a patient’s medical stability, psychotherapy is not the main course of action, but the goal is then instead to preserve the patient’s life. This is when the protocol falls under restrictive treatment:
- The average length of stay in the hospital is 10 days.
- The focus is on making sure that the patient is getting the nourishment and nutrition that they need.
The goal is not to get fat; the goal is to become medically stable. The hardest part for these patients is the understanding that the improvement means weight restoration to a certain degree, which means gaining weight, and that is completely terrifying for someone who is suffering from an eating disorder. (Dr. Michael Wetter)
Residential treatmentWhen a patient is in residential treatment, they live in accommodation and take part in a program that provides immersive treatment.
- Patients have all their meals there
- They take part in group and individual therapy
- Nutritional therapy is provided.
I would venture that for many of these patients it is a shock to the system because the child is not being confronted, it’s the eating disorder that’s being confronted, and it has nowhere to run. (Dr. Michael Wetter)The average length of stay depends on the facility and the individual, but it can be anywhere from eight to 12 weeks.
Partial hospital program treatmentPHP treatment is similar to day-treatment where the same types of programming are afforded: individual and group treatments, nourishment, medication prescription. The difference is that patients go in every day and then go home at night. PHP treatment is a step-down from residential to going back home.
Intensive and traditional out-patient programmingIOP treatment is similar to PHP where a patient stays at home and goes in for treatment anywhere from three to five days a week. A patient may have a single meal at the hospital or treatment center instead of having all three meals. The focus here is on individual and group therapy instead of focusing solely on medication. After intensive comes traditional outpatient programming, where a psychologist and dietician or an ad-hoc team will work directly with the patient.
The most important part of all of this is getting the initial assessment and not making the assumption that this is the level of care that my child needs, but really getting that professional assessment and recommendation of “this is where they can best be served at this state and at this place in their diagnosis”. (Dr. Michael Wetter)
Different treatment modalities
- Cognitive-behavioral therapy (CBT)
- Family-based treatment (FBT)
- Family-based therapy
I would encourage parents to really understand FBT more before you say “yes” … FBT is really creating a residential treatment program at home. (Dr. Michael Wetter)
Books mentioned in this episode:BOOK | Dr. Michael Wetter - “Earn It: What to do when your kid needs an entitlement intervention” BOOK | Dr. Michael Wetter - “What Went Right: Reframe your thinking for a happier now"
- EATING DISORDERS AREN'T ABOUT FOOD? WHAT? LET'S TALK.... | EP 53
- Visit Dr Wetter's website
- Nourish for Life Out-Patient program
- Sign up for the free Behind The Bite Course
- Practice of the Practice Network
- Email Dr. Cristina Castagnini: firstname.lastname@example.org
MEET DR. CRISTINA CASTAGNINII am a licensed Psychologist and Certified Eating Disorder Specialist. While I may have over 20 years of clinical experience, what I also have is the experience of having been a patient who had an eating disorder as well. One thing that I never had during all of my treatment was someone who could look me in the eye and honestly say to me "hey, I've been there. I understand". Going through treatment for an eating disorder is one of the hardest and scariest things to do. I remember being asked to do things that scared me. Things I now know ultimately helped me to get better. But, at the time, I had serious doubts and fears about it. If even one of my providers had been able to tell me "I know it's scary, but I had to go through that part too. Here's what will probably happen...." then perhaps I would not have gone in and out of treatment so many times. My own experience ultimately led me to specialize in treating eating disorders. I wanted to be the therapist I never had; the one who "got it". I will be giving you my perspective and information as an expert and clinician who has been treating patients for over 2 decades. But don't just take my word for it...keep listening to hear the truly informative insights and knowledge guest experts have to share. I am so happy you are here!
THANKS FOR LISTENINGDid you enjoy this podcast? Feel free to comment below and share this podcast on social media! You can also leave a review of Behind The Bite on Apple Podcasts (previously) iTunes and subscribe!
[CHRISTINA 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. Well, hello, hello. So excited to be here today with you guys. So the other day it just so happened that I got a few calls in a row into my private practice, and they were from parents who were, rightfully so very concerned about some of the behaviors they were seeing in their kids and they wanted to know all sorts of things, including if I was even the right person to be calling. And you know what, I completely get it, seeking mental health services is really not a very well understood process by a lot of people and just in general, it's really confusing. But when someone is trying to seek help for disordered eating or an eating disorder it's even more confusing and difficult. Oftentimes people don't know who to contact or what help even looks like. It can be confusing to understand even like once I try to explain it to someone in a brief phone consultation, because quite simply, it's not quick and simple to explain. There really is a lot to it. And as a parent myself, I can completely understand that trying to take in so much information when all you want when your child is hurting and you want to get them help is really, really difficult. So I thought, why not have an entire podcast discussing all of this to really break it down so that anyone out there listening can understand what to do if you think you or someone needs help from an eating disorder. After this podcast, I really hope you can walk away knowing how to seek treatment, what the different levels of treatment are, and really just have an overall better understanding about eating disorder treatment in general. Then I thought, well, who do I bring on to talk about this? Now, who better to bring on than a guest who's out there, who has years of experience treating eating disorders, and who's currently treating them on all different levels of care? Dr. Michael Wetter is a clinical psychologist with over 25 years of experience, who has a private practice in Los Angeles and is the Director of Psychology at UCLA Medical Center, Division of Adolescent & Young Adult Medicine. He's an Adjunct Professor of Psychology at Pepperdine University and has served in leadership positions at nationally ranked hospitals including Kaiser Permenante and Cedars Sinai Medical Center. Dr. Wetter is an award-winning author of books including “Earn It: What to do when your kid needs an entitlement intervention” and “What Went Right: Reframe your thinking for a happier now." Both can be found at Amazon. I'm so excited to have him on. So welcome Dr. Wetter. It's great to have you [DR. MICHAEL WETTER] Nice to be here. Nice to speak with you. Thank you so much. [CHRISTINA] So it's been a while since I've actually seen you or spoken to you. We actually worked together at Kaiser a very long time ago. [DR. MICHAEL] Eons ago. [CHRISTINA] Yes, we're both in very different positions now in our careers, but so exciting to hear what you're doing now. Would you mind talking to us a little bit about what position you're at and what you're doing now? [DR. MICHAEL] Sure. And thank you for having me on your podcast. I enjoyed immensely and I think it's a valuable resource for so many out there. Currently I sort of do a couple of different things. I have my private practice, which is located in Los Angeles area where I work with clients, both in person, as well as through telehealth and then I also serve as the Director of Psychology at UCLA, specifically in the division of adolescent young adult medicine, where I oversee and clinically work in two distinct programs for eating disorders, one of which is an outpatient clinic that's called Nourish for Life. The medical director for that is Dr. Elaine Rosen. She started this program about four years ago. We also have a second program that sort of, if you will, coincide with this, although it's not directly related, which is the medical stabilization program. The medical stabilization program is for those individuals who require to be hospitalized on an inpatient level because their weight has gotten so low that it's now dangerous and requires more direct eating and supervision from a medical standpoint so they don't experience refeeding syndrome or some of the other medical complexities that can come with being malnourished. So there are sort of, I see kind of both ends of it. I see where it becomes really quite progressed and advanced and serious in its nature. And I also see it on the outpatient level from the perspective of initial assessments. So people coming in from the very get-go who really don't know what's going on, they may not even be aware that there is an eating disorder. There may not be an eating disorder, but it's our job at that level to sort of do a comprehensive assessment from a medical standpoint where Dr. Rosen will be the pediatrician and specialist there who does a complete evaluation and assessment on my level, the psychological assessment to see what's going on that front. And then we also have a dietary component where a dietician will also meet. And we sort of put our three relatively sized brains together, and we come up with one super brain assessment and make some recommendations from there. So that in a nutshell, in addition to lecturing here and there, and the occasional high quality podcasts that I'm invited to do, that's what I've been doing. [CHRISTINA] That's amazing. I'm just listening to that kind of assessment and thinking, okay, how does somebody even get in the door to get that kind of comprehensive assessment? [DR. MICHAEL] Yes, I will tell you this eating disorders were certainly not created by the COVID pandemic, but the COVID pandemic did not help eating the disorders at all. And we now have waiting lists for our program that stretches into even now February of 2022 or anticipate, which is a lifetime for a concerned parent. It's a lifetime. And we do our best. Our program is also experiencing unprecedented growth where for the past few years it's been really just the three of us, and now we've been approved to hire more staff, which we're really looking forward to, but it takes some time. So what gets somebody to our program, which is unique in our area, which is surprising given Los Angeles and the demographics, but we really are unique, we'll get some of that is usually a recommendation or referral from either a pediatrician who's treating a child who's concerned about weight loss or anything else for that matter, or it's word of mouth and from other families and other parents and people who just start speaking and looking into resources and so forth. So it's very different than let's just say, calling up somebody a therapist or psychologist in private practice saying, "I think my child has an eating disorder," and starting the ball rolling there. Here we really do have that comprehensive approach where we can really look at it from all angles. And I think that way, when we make a recommendation of what we think are the next best steps, whether it's working with us needing a higher level of care or something else for that matter, they know they're getting it, not just from a singular perspective, but really comprehensively. [CHRISTINA] So now, do you just do the assessment or do you actually also treat the patient that comes in? [DR. MICHAEL] One-stop shopping. I assess and I treat. [CHRISTINA] Okay. [DR. MICHAEL] And the treatment modalities that we tend to use include CBT for those who are more adolescent focused or young adults and focus in that regard or FBT, which stands for family based treatment. [CHRISTINA] Okay. So you work with the families of adolescents and young adults? [DR. MICHAEL] Yes. And I would go so far as to say I work more with the parents than sometimes the extended family, as and again, this is probably more a product of COVID where interactions are really sort of severely curtailed by hospital policies about who can come and who can't come. So ideally what we would like to have, you know siblings and extended family members who live in presence in the house and who contribute to the family meal, you participate, that hasn't always been an option in the past year and a half. So it really is kind of shrinking it down to those core essential members of the family. [CHRISTINA] So this part you're talking about is the outpatient program. So for listeners who may be a little bit confused, can you discuss a little bit about the difference between what would qualify somebody for an outpatient I guess, level of care, versus the other part you were talking about, even the higher levels of care. Like when you get somebody and say, okay, they are somebody we'll treat in an outpatient basis, how would you determine that? [DR. MICHAEL] Sure. Let's be very clear. We're all confused to a certain degree and a certain level. Doctors, physicians nurses, clinicians, dieticians, everybody has their own opinion and everybody's confused. So it would be arrogant for me to say, "I know the distinction and let me tell you what to do." But I'll give you my impression and my philosophy when I consider that. There are multiple levels of intervention for everybody that comes through the door. The first thing you have to assess more than anything else is what are we treating? What is the disorder, if there is one. And some of the more common examples of what we see are certainly anorexia nervosa, the various subtypes. We also see some degree of bulimia nervosa and whether that is in the context of anorexia with binge per cycles, or more specifically an isolated, I shouldn't say isolated, but a specific bulimia nervosa, independent of anorexia. And then we also see a high degree of ARFID, which is Avoidant Restrictive Feeding Intake Disorder. And then sometimes we see nothing at all and they just come in because they didn't realize that there was more disordered eating than an eating disorder. And it's just sort of a point of clarification. What we really determine, the disposition and the most effective recommendation is where along the line of the continuum of the particular disorder does the patient fall? So for example I'm just going to stay with anorexia nervosa right now, not to minimize the other disorders or conditions, but rather because that seems to be the most prevalent one we've seen both recently. And to be fair, extremely dangerous, as we all know is how far along is the particular individual in their malnourishment? So for example, if we are starting to talk about people who are presenting, who are either tachycardic or bradycardic, where they are experiencing dips in their phosphorus, in their production of whether it is glucose to the brain or whatever else, it may be we're seeing compromised functions in their blood work, in a metabolic workup. And as you will know, probably in seeing it, when you sit with someone and they just have brain fog where you really can't connect with them and their ability to concentrate, relate, emote and express is compromised. When someone's reached that level and we're concerned about their medical stability we're not even at that point in time concerned about psychotherapy. The goal right now is to preserve life and that's where medical stabilization is required. So that would require inpatient hospitalization on a medical unit, the average length of stay being about 10 days. At this point in time, the focus is on really making sure that the individual is getting the nourishment and nutrition that they need. This doesn't mean healthy food. It means all food is healthy at this point in time. And we have a very specific protocol of which we follow where the amount of calories and the nourishment is really dictated by the dietician of the service supervised by the hospitalists and overseeing physician. And it steadily potentially increase every day, depending on what the needs of the patient are. The goal is not to get fat. The goal is to become medically stable. The hardest part for these patients is the understanding that improvement means weight restoration to a certain degree, which means gaining weight. And that is completely so terrifying to someone who is suffering from an eating disorder. So the role of the psychologist in this particular, and I'm talking now specifically about my role, when it comes to medical stabilization and inpatient hospitalization, it's not therapy, which is so contrary to what parents often think their child needs. Where's the therapy? They're suffering. The primary focus right now, isn't therapy and that's because the brain is malnourished. When the brain is malnourished, cognitive functioning is impaired. Psychotherapy at this point, it's like banging your head on a wall. You're not going to get anywhere. So really my role was one to assess what is the degree of impairment? What are the other underlying potential psychosocial and emotional, effective cognitive things at play. Are there any other comorbid psychiatric diagnoses that we need to be aware of? Lending support, psycho-education not only to the patient, but to the family and then coming up with an appropriate disposition. After they reached medical stabilization, what comes next in the treatment, which is often the springboard for their care. So all those things go into play. So it's not uncommon for someone to come into our clinic, our outpatient clinic thinking they're going to receive outpatient services and in fact, find out that day, they need to be hospitalized. Big shock. But at the same time, it's a big shock and more often than not, it's a big relief. It's a big relief because it's now about safety. And the parents feel the sense of relief because one it's validation that something actually is going on and two that their child can get what they need. There's an underlying philosophy to what we do, which is food is the medicine. And that's really sort of the underlying current and I would say sort of the predominant message that we give families when they get in the hospitals, food is medicine. And there may not be medicines that you like or taste to your preference, but we still have to do it and we're going to do it in the most supportive and mindful way we can. But it's still a challenge and I think parents feel the most relief knowing that their child is safe. And one of the things that I make a point of trying to, because they, especially at the outset of the hospitalization is look, you know your child, but we know the disorder and what we want to do is collaborate and how do we work together so that you can get your child back from this disorder, which is more often than not taken over. It requires hospitalization. So that's the one level. I can do a deep dive on that all day, every day, but that's the one level of care and that I would call that the most restrictive level of care. They're in a hospital bed, they're not going out, they're really sort of confined to that treatment model at that point in time. I'm just going to go down the ranks in terms of, least from most restrictive to least restrictive, to explain the various levels of care. So let's say somebody makes it through that hospitalization and in a period of like say 10 to 11 days, they are now medically stable, where any cardiac issues have been sufficiently restored and attended to, metabolically they're stable. Psychologically they may still be distressed, they may have had a shift in their thinking any number of things, but they are ready to be discharged from the hospital. Typically at that point in time, we recommend that the next level of care be residential treatment. Residential treatment is where the individual will actually stay at the treatment facility. Here in Los Angeles, there are typically houses that are nicer than what I live in. They're palatial, they're mansions and you have upwards of about anywhere from maybe seven to 12 kids, usually, if we're talking about adolescent group, anywhere from 12 or 13 up to no older than 18 years old. Usually 18 is a cutoff for an adult program where they are all invested in a program that provides immersive treatment. So all their meals they have there. There is around the clock activities and processes that occur that can address the treatment. And that includes group therapy, it includes individual therapy, it includes nutritional therapy in most cases and involves opportunities to participate in some form of schoolwork so they don't fall so far behind. Really what residential provides for many of these patients more than anything else is an immersive treatment experience. And the way I sort of explain it to parents when they're saying, "Well, we really want to try to manage this on an outpatient basis. Can't they come and just get therapy once a week or even twice a week and do well?" the analogy or metaphor I will often share with them as well, let's say you wanted to learn French. My daughter lay is taking French in school this year, and now she can identify with this metaphor. If you want to learn French, I can tell you, look, I've got this guy. His name is Pierre. Pierre is from Paris. He's a great guy. He knows his stuff. He knows French. He can come over and work with your child two hours a week to teach them French. He is fantastic. Like I said, he knows the language backwards and forwards, and we can do that for about, oh, let's just say six months. Or I can send your kid to live in Paris for two months. Which way do you think they're going to learn the language in a more comprehensive and again, key term here, immersive way? What are they going to take more value from? It's no slight on Pierre. It's not a slight on them. It's the process. And that's where residential treatment really is so critical oftentimes for the patients who need it. It's the immersive experience of it. And I would venture that for many of these patients. It is a shock to the system because the child is not being confronted. It's the eating disorder that's being confronted, and it has nowhere to run. And that's where you can sort of burst through. Average length of stay depends again on the particular facility and it depends on the individual as well, but can be anywhere from about eight to 12 weeks. And from there, we have the PHP level of care, which stands for Partial Hospital Programming, which is ironic because there's nothing to do with the hospital. It really is kind of like day treatment where the same of programming are boarded, which is individual group medications as needed and if needed as well as dietary, the difference being is you're going everyday, but you're coming home at night. So it's kind of a step down and if you will transition from residential to now matriculating back at home. After PHP comes IOP, which stands for Intensive Outpatient Programming. There again, you are staying at home. You're not going every day of the week. You may be going anywhere from three to five days a week and instead of having breakfast, lunch, and dinner there, you may be just having breakfast or lunch or some combination thereof. Again, the focus now is less on the medication aspect of things, but more on some individual as well as group therapy. And from there, we step down to what is considered to be traditional outpatient. And that can either be in a program like where I work, where it's sort of a team approach of physician, psychologist, a dietician or an ad hoc team, which is consistent of a private practice clinician, a dietician as well as pediatrician or physician following along. So, like I said, there's so many different places to get confused, like where do I go? And where do I start? And I think that the most important part of all of this is getting the initial assessment, not making the assumption that this is the level of care that my child needs, but really getting that professional assessment and recommendation of this is where they can best be served at this state and at this place in their diagnosis. [CHRISTINA] Well, and I think the way you're doing it is fantastic. Now as someone who's in private practice who does more of what you've described as the ad hoc, bringing in --- [DR. MICHAEL] I'm part of the ad hoc system. I live in it and I breathe it. So I got nothing, but it's nice to have a team. [CHRISTINA] Oh, absolutely. And I think one of the biggest frustrations is trying to find someone who is in the medical field, who is well-versed in eating disorders as well. So I don't know how you've been finding that on that level too. There's a lot of maybe conflicting information, or maybe even conflicting assessments going on. So for somebody who might be listening where would you suggest, a lot of people first go to their pediatrician or they first go to their medical doctor and maybe not a therapist or psychologist. So for anyone listening, would you suggest they actually go to a psychologist first? [DR. MICHAEL] Well that's, as a psychologist, of course I'm biased but I'm a big believer in that the data tells a story. So I think what is important is start with gathering your data. So if you suspect something is wrong, I would definitely go ahead and set up an appointment with your pediatrician, if, for anything, just to have a very important piece of data, which is the growth chart. Let's see what has been the trend in terms of weight or weight loss over the past three, four or five years? If we see a precipitous sort of drop, we know something is really wrong. If we just see a one pound or two pound difference, maybe we don't have to sound the alarm just yet, but we can start to explore it. [DR. MICHAEL] But that data is valuable. That data tells a story. I would get that first and then I would pursue consultation and assessment with a psychologist. I think the key here is someone who actually does know eating disorders. You know when you look on various therapy referral resources, a lot of people are very quick to refer to themselves as an eating disorder expert or that they deal with eating disorders. And again, it's not my job to criticize or assign blame to others, but I will just make this mention, not everybody who is listing everything on their side as a specialty can also be a master of everything. When we're talking about eating disorders, you really want someone who knows the beast, if you will. Someone who's very well-versed in the pathology, the psychopathology, the behaviors associated with it, what needs to happen, the various levels of care. You will know very quickly if you select the wrong person, because they will tell you very quickly, I am not the right person. Because the minute they see the level of severity, in some cases, they will realize that it's out of, they are out of their depth and they are out of their scope of practice. Eating disorder is very different than someone who struggles with weight loss. Eating disorder is very different than someone who's just a picky eater. And I think that it really, this is where, even though you're feeling pressured and quick, and you want to act out of desperation to find somebody, you want to find the right person and not just any person. It will save you more time and more aggravation in the end to do that investigatory work. Sometimes it's even asking, saying, "You may not be an expert, but can you recommend somebody who is?" [CHRISTINA] Right. And I guess to your point too, there's been a lot of times I've gotten somebody in and not even looked at the weight issue. You know, you brought that up in terms of medical necessity and somebody being on the brink of even death. And I find a lot of times it's the behavior and the eating disorder and the illness and it has nothing to do with what they actually look like on the outside or their weight. So that oftentimes really throw people because parents, teachers, other doctors, will say, "Well, you look fine. You must not have an eating disorder." [DR. MICHAEL] Exactly, exactly. I've never heard someone, I shouldn't say never, it is rare that I've ever heard a teenager or a patient in particular who says I started off wanting to be anorexic. The number one thing I hear is I want to just be healthy. So I want to try to start to be healthy. Parents hear that and they're like, "Yes, be healthy. Go for it, whatever it is." It's such an insidious and seductive disorder that it happens before you even realize it's happening and if you don't know what to look for, you are going to miss it, not because you're a mis-attuned parent. It has nothing to do with you being a good or bad parent. You love your child. You're there for your child. It's that it starts off in an innocuous way, which is, yes, I just want to eat healthy or I just want to lose a few pounds or I just didn't want to be that, I didn't want to have a COVID body and I have more time to myself and I just didn't want to, it could be any number of things. So it's not always about the number on the scale. It's not always about the size of pant or skirt or dress. You can even have atypical anorexia where the person is actually still considered to be overweight relative to what they're recommending, but it's the history. It's behind it. One of the things that I try to, again, adopting a user-friendly language as best I can with parents is the act of eating, of being nourished, would never be an overly emotional activity. In other words, someone shouldn't drive ecstasy from envisioning the next meal. And by the same contrast, someone should not be terrorized at the thought of the next meal. And when those are present, when we look at the emotional context that it occurs in, that's one of the things that we can look at in terms of terminating the eating disorder pathology. [CHRISTINA] Exactly. And you brought up something interesting, the ecstasy of eating. How often do you actually find people that you treat for binge-eating disorder? [DR. MICHAEL] I mean, it's prevalent. It's there. Interestingly enough, prior to my work at UCLA, I used to work in a department of surgery for bariatric surgery and doing a lot of bariatric,, weight surgical weight reduction, processes, and procedures. And one of the things you would screen for is binge-eating in present. Because that's going to result in some severe medical complications if they continue with that behavior after surgery. If removed, graft, 80% of the stomach associated with a gastrectomy, if you continue to binge you're quite literally going to bust a gut. So I'm very familiar with the pathology that comes with binge eating and it rarely is an ecstasy. It's more about sort of the self-soothing that comes with bingeing. And by the way, as we talk about sort of the emotional impact of either bingeing or in restricting, in some cases, I think it's important for parents to understand that the act of restriction doesn't just set off the pleasure centers in the brain in a kind of a psychopathological manner, but then it also acts as a numbing agent. Anorexia is what I consider to be emotional Novacaine and that the more you restrict, the less you feel and accept when you start to eat, that's where the anxiety manifests and it burns through. And not to be surprised that when we start to become more nourished and weight restoration begins that Novacaine wears off and now we're left with all these things. So I have parents saying, "My child is looking worse. They actually sound worse than when we brought them in and worst emotionally." It's all been there all along. You know, if you have a root canal and they don't use Novacaine, you're going to feel it. And when they use Novacaine and the Novacaine wears off, you're going to feel it. They didn't make it worse. And that's a really important thing to bear in mind. It's that's why medical stabilization or weight restoration isn't the end of treatment. It really is just the foundation for the treatment that is yet to come. I am so glad you said that because I get so many parents I've worked with, well, they're following their meal plan, their weight's restored, "We don't need treatment anymore." And I'm going, "Oh my goodness, that's not it. That's not what's happening here. That's not the eating disorder just being done now." So I'm so glad you cleared up two things. One is like food for pleasure and ecstasies, not binge eating. It's using food for something else. I'm glad you cleared that up. But also it's not just the behavior that is okay now the behavior's better, the eating is better now, the illness is gone. Because that's no it. There's underlying issues. [DR. MICHAEL] It would be like saying you're the captain of the Titanic, like, "Oh, we see that little tiny iceberg there. We got that," and not realizing, oh my God, it's the hemophilia underneath that's going to tear us apart. There are so many traits that are consistent with eating disorders and specific anorexia nervosa that we don't want to acknowledge our traits of the disorder, but rather that the disorder hijacks for its own purposes. So we see individuals who are highly driven, highly intelligent, who are perfectionistic in their tendencies, who tend to need things to be a certain way, they're routinized in the way they do things. And again, we look at this, I can't tell you how many times parents come in, "My daughter or son is a straight A student and they play three different sports. They have intentions of going to Yale or to Oxford, to Stanford or to Berkeley or whatever it may be." So I know they're fine because they can do all that and they're doing great and it's like, that's exactly the reason why they are so advanced in their anorexia nervosa. It's because whatever traits and capacities and strengths your child has, so does the anorexia. So you can't just stop with, well, now they can go back to being a straight A student and driven and everything because anorexia hasn't gone. It's just silent. [CHRISTINA] Exactly. I'm so glad you brought that up too, because that I see that with so many people I'm working with, those criteria exactly. And when I ask them those things, like, "My gosh, that sounds just like me." [DR. MICHAEL] I frame it as a game. I'm going to play a game here. I'm going to give you my game of assumptions and you tell me if I get it right or you tell me if I get it wrong. And they're like, how did you know that? It's even thrown to our garbage. What does he know about me? And it's like, have I had their systems? Like, no, this does not mean that those traits are bad traits. They're just being hijacked and used by your disorder in a negative way that's working against you versus for you. [CHRISTINA] Right. Well, Michael, I know I've said it a lot of time here today, and you said so many great things that I hope people are really listening to and can really help guide them for when they are hopefully seeking treatment if they think they might have an eating disorder and need to go in for an assessment. And maybe some parents can have some clarity now about what the levels of treatment are, because I do think there's a lot of confusion and a lot of it's like a mystery out there. Like, what is it all? Do you have any last words or anything you'd like to share with the audience? [DR. MICHAEL] Any last words? I hope I have many, many more words to come and for years to come, but I'm never at a shortage of words. I think there's also an important thing just to say, and I would encourage your listeners to pursue this more in their reviews, which is the different treatment modalities, which includes Cognitive Behavioral Therapy, which is CBT as well as Family-based Treatment, FBT and a quick qualification FBT, Family-based Treatment does not equal family therapy. I think so many parents are quick to, they're like, "Yes, we'll all get in there and we'll do what is necessary." It really needs to be quite extensively explained that what FBT really represents, it's putting the parents in charge of the patient's food and nutritional recovery. And that parents are often shocked when we begin FBT that the psychologist or therapist you're working with actually is meeting with you, the parents, not your child, because the first goal is again, weight restoration, nourished brain, nourished mind, that's when therapy can occur. So I would encourage parents to really understand FBT more before you just say, yes, we're going to jump into it. What I will often say is FBT is really creating a residential treatment program at home. A residential treatment program for one, it can often mean that you have to take time off of work, that you have to be there all hours, that you are essentially going to be the bad guy in the eyes of your child's eating disorder and how to get through that. What's so wonderful about it is treatment in the past, usually excluded the parent and the treatment of eating disorders and now you are agents of the treatment, if not the head of the treatment, so to speak. And that your treatment team members, psychologist, dietician, and/or physician are there to support you. So I will just encourage parents to look into those distinctions and to have an understanding and if you don't, ask the psychologist or therapist you're working with so that you do have a better understanding of what you're signing up. [CHRISTINA] Oh, I'm so glad you clarified that too, because I do find that that is very much misunderstood. So thank you for that. And I'm glad that there's more education out there for parents to just, there's a lot more information on the internet too and I do think that's part of our job as a psychologist, to educate parents. So thank you for all of the information you just provided. Very helpful and useful. [DR. MICHAEL] You've never asked me if I have any more to say. But thank you for having me. I really appreciate it. [CHRISTINA] All right. So if people do want to find you or learn more about the program you just discussed, how can they find you? [DR. MICHAEL] Well, there are two different paths. Certainly you can explore UCLA or UCLA Health. We're in the process, as an organization of reformulating our website. So we don't really have a strong web presence right now, because it's all being done and was put on hold a little bit for the, sort of the pandemic. However, you can contact a UCLA adolescent medicine department and say that you're interested in learning more about the Nourish for Life Program. You don't get any discounts or priority by mentioning my name, so there's no benefit to doing that, but you certainly can get through and learn more about the program there. In terms of me and my private practice and so forth, it's a very narcissistic link, drwetter.com. That's it. And I'm happy to field any questions or provide any consultation that people may have. [CHRISTINA] Fantastic. And if anyone missed any of that, I will have all of that information on the show notes. So don't worry about that. It will all be there. All right, Michael, it's been so great to have you on the show and reconnect with you after all these years. Thank you so, so much. [DR. MICHAEL] Absolutely. Thank you for having me. [CHRISTINA] 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.