Andrew: I’m pleased to have Lori Osachy, MSS, LCSW, Clinical Director of the Body Image Counseling Center in Jacksonville Florida, and founder of text2Bwell in partnership with CareWire. Now, text2Bwell is an eight-week text-messaging program to transform the way people feel about their body. Lori, thank you so much for joining us at Serene Scene Magazine today.

Lori: You’re welcome, it’s my pleasure.

Andrew: Okay, Lori, I have to ask, what got you involved with eating disorders?

Lori: Well, as I always like to say, I was kind of doomed, because my father was a therapist, so it ran in the family. He was a counselor and a therapist.

But what got me started in eating disorder treatment was truthfully that a very good friend of mine almost died when we were young from an eating disorder. And it was so poorly understood, that experience always stayed with me. And then, of course, it is one of the epidemics of our time among women, and increasingly, men.

Andrew: I read that there are 20 million women and 10 million men just in the United States that suffer from clinically significant eating disorders at some time in their life.

Lori: That’s actually probably on the low side, because a lot of people don’t report.

Andrew: I also read that one out five eventually die from this.

Lori: Yes, 20% of people will die from the complications of an eating disorder. But, with the right treatment, that statistic can go down.

Andrew: I mean, that is a significant burden on our society. Why do you think it is that we don’t know more about eating disorders?

Lori: It’s a great question. Unfortunately, eating disorders are often shrouded in a lot of shame and secrecy. And I think that treatment is not well funded. And so, all of these factors conspire together to keep this, the most deadly of the mental health disorders, that is not adequately treated.

Andrew: And you talked a little about the stigma as well. I would imagine there are many people out there that don’t have a full understanding of what eating disorders are all about. And they might just say, well, why don’t you just eat something? Or why don’t you just not eat all that junk?

Lori: Right, that happens all the time, or how could you throw up your food, or that is true. And a lot of times, too, the eating disorder behavior is normalized in our culture. I always say that we live in an eating disordered culture that is very skewed around food, weight, and body image.

Andrew: So there’s a couple of different things about eating disorders that I don’t fully understand. So maybe you can help me understand them a little better. You speak about subclinical disordered eating. And then you also speak about the disorders that we all know, like anorexia and bulimia. So what’s the difference between those? And how do they interact with each other?

Lori: There’s often a misconstrued idea that people develop one type of eating disorder, and that’s it. But the truth is, most people experience a range of eating disordered behavior throughout their life, along with other self-soothing mechanisms, including substance abuse. So anorexia, the definition of anorexia is losing up to 85% of your normal body weight through food restriction.

And there are different subtypes, purging and non-purging. Bulimia nervosa is using methods of purging to, well, first, you binge on high-calorie foods or binge on food beyond the point of hunger. And then use a purging method such as making yourself throw up, use of laxatives, diuretics, enemas, or diet supplements, or compulsive exercising to purge those calories out.

There’s also compulsive overeating, also called emotional eating, which is eating beyond the point of hunger for emotional reasons, and gaining weight because of it. Then you have other subtypes, such as body dysmorphic disorder, which is when you don’t like one part of your body so much that you use excessive plastic surgery procedures to alter it. Or it’s difficult to leave the house because of it, very high anxiety, so those are a lot of. And additionally, there’s a new type of eating disorder, which isn’t in the DSM. But I’m seeing more and more of that in my practice, which is orthorexia, which is an obsession with clean eating, to the point of starvation.

Andrew: Clean eating, can you describe what clean eating means?

Lori: Well, sometimes it’s different for different people. And again, it’s normalized and encouraged in the media and through the food industry. So it’s basically, there are certain foods that are not considered not clean, meaning they’re fattening or they’re going to hurt you in some other way. So you have to keep them out. So it’s like these dirty foods as opposed to clean foods. So, for example, not eating carbs or only eating organic food is an example of clean eating. But what we end up seeing in practice is people that take that to such extremes that they limit their food choices so drastically that they end up starving.

Andrew: Now, the subclinical disordered eating, how is that different than some of these clinical diagnoses that you just talked about?

Lori: Well, I think that goes back to the fact that there aren’t many people who are healthy around their eating. And a lot of us have eating disorder thinking or behaviors that may not qualify for clinical diagnosis, but they still impede your life.

So, for example, if you’re dieting your whole life, counting calories, watching your weight, that impedes your life, causes a lot of anxiety, results in yo-yo dieting, up and down weight. And can really make your life difficult, even though you might not be clinically diagnosable.

Andrew: I see, so still, subclinical disordered eating is still impacting the quality of someone’s life to a significant extent. They just don’t pass, perhaps, the diagnostic criteria in the DSM?

Lori: Exactly, and then when you think about body image, which is one of the reasons we developed the text2Bwell program. A lot of people have terrible feeling about their bodies, to the point where they avoid social situations or relationships or applying for a job. Because they feel so badly about how their body looks. So even though it’s not affecting them maybe physically, it’s really hurting them emotionally.

Andrew: Okay, great. Well, thank you for clarifying some of that. Now, let’s talk about a family, or maybe somebody with a spouse that may have some kind of problem going on with their body image or with eating. How does one go about helping intervene on these kinds of disorders?

Lori: Well, that’s a great question, and it really depends on the diagnosis. So, for example, with anorexia, that’s the most dangerous of the eating disorders in terms of intervention. Because the thinner someone gets, the fatter they feel. And they are more likely to be in denial about the fact that they are in a life-threatening situation. So it becomes even more important that the people around the anorexic person confront them and Intervene to help them get treatment, it’s a lot more difficult. Someone who has bulimia is maybe very ashamed about being bulimic, but they know they have a problem. And so they are more likely to, when some intervenes or notices signs of the bulimia, they’re more likely to ask for and receive help. And the same thing with emotional eating or binge eating, or with orthorexia.

Andrew: From a mental health perspective, what are the causes of eating disorders for most people?

Lori: They range, the causes range, like you said with a broad stroke. But a lot of people were bullied when they were children about their weight. And a lot of times, that results in extreme dieting to try to avoid being the weight they were when they were bullied. So that’s very common.

Sometimes family trauma, family difficulties, dysfunctional family situations can trigger an eating disorder. Sometimes just our dieting culture can trigger eating disorders, seeing unrealistic idealized body types in the media. Being pushed to be super thin, or with boys and men, to be super buff and ripped, can result in compulsive exercising and dieting and purging behavior.

Andrew: It strikes me as very interesting that the things that you just mentioned, the trauma, the shame, peer influence, these are all things that lead people to drug and alcohol and abuse as well. So there must be a link between eating disorders and substance abuse. Now, can you talk about how that works hand in hand?

Lori: Right, actually, studies show that someone with an eating disorder is much more likely to develop a substance abuse problem than the regular population, and vice versa as well. So these are very vulnerable populations on both sides. And they’re both self-soothing mechanisms, so it makes sense. As I was saying before, it is typical for someone to come see me for treatment who developed an eating disorder later in life. But they were substance abusers when they were young. So, for example, a woman might come to me and say, I was a drug, alcohol abuser when I was young. But then I got pregnant, and I didn’t want to hurt the baby, so I quit, but never dealt with the underlying reasons, so I started bingeing and purging.

Or vice versa, someone with eating disorder when they were younger then got to college and were around a partying culture. And they started using drugs and alcohol and less eating disordered behavior. But if you don’t get to the root of it, you can go and switch self-soothing mechanisms throughout your life.

Andrew: Now, I have a third grader in my life, and he has already expressed concern about his potbelly.

Lori: I know, I’ve had other interviewers tell me that, too. Children identify the word fat as negative by the time they’re five years old. I mean, the average age that children start dieting is eight years old.

So there are things you can do about it, but it is important to do preventative care to try to buffer our children from eating disorders. Because when they hit their teens, that’s when it gets really bad. So there are definitely things you can do if your child is telling you that they don’t like their bodies at that young age.
Andrew: And what can we do as a parent or as a clinician? If we’re working with a family system and maybe we see that in one of the family members, how do we address this?

Lori: Well, it’s a great question. So it’s not easy, it’s not easy. So, but one of the things you can do is you can start to point out to your child, even at a very young age, when there are unrealistic pictures of models on TV and in magazines. And to start to educate them that a lot of those pictures are airbrushed and doctored in ways that the model doesn’t even look like it. So you could tell them, if you see a male model, you can say, he probably has a little pot belly too. But they erased it, and they put in some extra six packs there.

You can also tell your son or tell your child that people come in all shapes and sizes, and that everybody is beautiful. And that it’s not normal to think about having a flat stomach, that that’s not the human condition. And you can even show them your stomach and show them other people’s stomachs, and not be ashamed of your own body. That’s a big help for kids, to say, hey, I love my body. I’m busy doing in the world, not worrying about what my body looks like. And as long as you eat according to hunger and exercise for fun, your body is perfect just the way it is.

Andrew: So if we get someone to agree that they do have a problem going on here, and they do need to seek some professional help, who do we look for? And what kind of treatment works for eating disorders?

Lori: It depends on how severe the eating disorder is. So the first thing one needs to do is see their doctor. So the doctor runs certain tests to make sure that you, and takes your weight and makes sure that you’re even healthy enough to receive treatment on an outpatient level.

So there are many fine inpatient programs, if that’s not the case, that can help to stabilize symptoms. But if you are safe to be in an outpatient treatment setting, you want to look for, first of all, a clinician that works with a team, doesn’t try to do it alone. That’s a warning sign, if a therapist is saying they can counsel you on nutrition as well as the therapy, and as well as the physical part, that’s a danger sign. You should not go to see that person, because a therapist isn’t trained as a nutritionist or a doctor and vise-versa. So you want to have a team treatment approach, where your doctor, your therapist, and a nutritionist are working together, sometimes with a psychiatrist as well, to help you towards your recovery.

Andrew: Are there specific approaches used by the therapist that seem to be more effective than others, or is that just individualized?

Lori: Well, it does depend on the individual and the situation. But there are certain treatment techniques that have been shown to be more successful. So, for example, with an anorexic child, the Maudsley Approach is an approach which coaches parents to re-feed their child at home. Has been proven to be very successful with certain types of families.

Cognitive techniques, cognitive behavioral techniques and dialectical behavioral therapy, and group treatment has been proven to be very helpful. On top of it, you must have nutrition counseling. A lot of times, people come to me and they say, why do I need a nutritionist? Because I know how to eat, I know what’s healthy and what’s not. But the truth is, it’s just not about knowing what to eat, it’s why you’re afraid to eat it. And a lot of times, people hold beliefs about food that are not healthy beliefs, even though they think they are. And the nutritionist can help counter those.

Andrew: I would imagine that just like chemical dependency issues, that eating disorders also have a very high relapse rate. Is that true?

Lori: Yes, it’s true. But with the right treatment, that rate goes down. A lot of times, I think people relapse because they don’t get the right kind of treatment in the first place. So they see a therapist or a doctor that’s not experienced enough in eating disorders and is not firm enough. And so they don’t recover all the way, if you know what I mean. They only partially recover, and then they relapse. Listen, I don’t do this work because I see people relapsing all the time, you know what I mean? I’m very hopeful that people can recover with the right kind of treatment.

Andrew: Yes, absolutely. Now, are there a multitude of support groups out there for individuals once they have engaged in treatment and find themselves in a recovery program. Can they reach out? I mean, is there a mechanism there so that they can get with other folks and continue to provide that self-help component?

Lori: I wish I had a more hopeful answer for that, but not always. It really depends on where you live, and it’s hard to find outpatient support groups. Which is unfortunate, because groups have been shown to accelerate recovery. Talking with people who’ve been through the same thing and encouraging each other to keep up recovery is very helpful.

And again, that’s one of the reasons we developed text2Bwell, so people would have an online method of support. Now, it’s not a support group. But it’s a place to be able to talk about your troubles in a confidential environment and receive support from other people around body image.

Andrew: And I think it’s exciting that you’re using technology in this way. So let’s talk about text2Bwell and how it actually functions. If somebody signs up on text2Bwell, what happens?

Lori: Right, so it’s very easy to sign up. You just text, be healthy, to 44222, and then you can register. And once you register, you are registered in an eight-week positive body image program, and you receive three texts a week. The first text is a tip to help you improve your body image. The second text is a challenge step, or an action step, where you’re given a concrete way to practice. And the third text is a link to a confidential forum where you can post on how you’re doing on the challenge. Get support from me, I’m in the forums as well, and support from other participants, so you’re encouraged to continue.

Andrew: I understand the three texts a week, that’s pretty straightforward. But the forum support, that’s interesting to me, because there’s a confidentiality component going on here. And technology is permeating the therapeutic community at the moment. And there are discussions around confidentially, and how do you use technology without breaching patient confidentiality. So how are you doing that with text2Bwell?

Lori: Right, so first of all, people are using a first name only, and they can use a pseudonym, which is nice. So since this isn’t a therapy group, people can really feel free to be totally anonymous, so that’s very helpful. It’s protected, protected forum. And also, having a therapist in there monitoring is making sure, if someone’s feeling suicidal or someone needs more help, that I can reach them directly.

Andrew: So when somebody signs up for this, are they giving permission so that a therapist can contact them if there are some big red flags that are popping up?

Lori: Yes, it’s understood that in the forums, you have to, if there’s dangerous behavior, that the therapist can contact you, absolutely.

Andrew: And that contact, does that take place via telephone? Obviously, it’s not within the forum.

Lori: It would be via telephone.

Andrew: And how have you seen this work for people so far?

Lori Well, I think that people are responding well. I mean, the feedback I’ve gotten, and we’ve just launched it and are piloting it, is that people are enjoying it. They’re not feeling bombarded by the texts, it’s just enough. That’s kind of, that it’s not invasive. And what’s really nice, too, I think, about the texting is that you receive the tip. But if you want more information, you can click on a link and get a lot more information and read more. But you don’t have to if you don’t want to. So we have a lot of content online that people can access, but it’s not necessary if you’re pressed for time. Also, I think there’s been a lot of very touching comments in the forums. People are really, what I’m really noticing is that these tips seems simple, but they’re not simple when you really face them and try.

And people are sharing about how much they’ve realizing negative body image affects their life, and that they really want to change, but it’s not so easy.

Andrew: There’s lots of information on eating disorders at which is your website. I also want to mention the website for text2Bwell, which is text, the number 2, the letter B,, if people want to check that out. Now, where else can people go if they need more information on eating disorders and how to get people help?

Lori: Right, so people can always go to my website, which is I offer free 15-minute consults, and I try to help everybody who calls me. Because I have a lot of parents that call and individuals that call that are very worried and don’t know where to go.

I’ve also written several books on Amazon. So I’ve written a parent guide that tells parents, if they think their child has an eating disorder, what to do, how to get a team together. And what questions to ask providers, so they make sure they get the right help the first time around.

Andrew: Yeah, this is a real specialty, isn’t it?

Lori: Yes, it is. I’ve written a college guide, as well, for college students, because eating disorders are rampant on college universities. One in four women on college campuses will suffer from an eating disorder.

Andrew: Lori Osachy, thank you so much for joining us at Serene Scene Magazine today. Good luck with text2Bwell and your future endeavors.

Lori: Thank you so much for having me today.

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