The Role of an Eating Disorder in Staying Stuck in Trauma

Shari Botwin, LCSW has been counseling survivors of trauma and eating disorders for over 20 years. She has been published and gone on air with several national media outlets. In this week’s post, Shari discusses the role of an eating disorder in staying stuck in trauma. 

I will never forget my first week working as a clinician in an eating disorder clinic in the mid 90’s. I was sitting in a meal support group and one of the patients spoke about how she was saving her life by confronting her sexual abuse during childhood. I remember thinking, “What does abuse have to do with anorexia, bulimia or binge eating disorder?” As the months and years continued more and more men and women were coming to my private practice with a long history of being stuck in an eating disorder.

Early in my career I got myself into therapy to explore the role of my eating disorder in staying stuck in my abusive childhood. For years I obsessed about my weight and at times ate to feel better.   I focused on my body parts, mostly the parts of me that represented being a woman and did whatever I could to try and make these parts disappear. As my recovery progressed I realized my eating disorder was protecting me from years of painful and horrific memories of my abuse. In my early adulthood I decided I want a full life and I was sick of “this stupid eating disorder.” I wanted to trust myself and others and I wanted to live life in a body I could sit in.

Something incredible happened around my 10th year in private practice. More and more patients were uncovering abuse, domestic violence, sudden family losses and tragic events like watching the planes crash through the world trade center during 9/11. As I digested and understood the role of my own eating disorder in staying stuck in my abuse I was able to help others realize the way their symptoms were not allowing them to move through their feelings of shame, fear and loss associated with the tragic events that led to a primary relationship with their eating disorder.

I can think of several examples even in the last year of being in practice where patients and I could make that connection. For example, I worked with one young woman who came to me at the age of 17. It took her 4 years to say goodbye to her anorexia. Within six months of being relatively symptom free she asked me, “Is it possible to be sexually assaulted by my own boyfriend?” From that point forward the floodgates opened. For months she reported incidents when she was hurt so deeply by her boyfriend. We began to understand that spending those 4 years prior obsessing and restricting food allowed her to keep the truth about her relationship secret from herself.

I remember working with another woman who came to me in her late twenties. She had been bingeing and purging for over 10 years. Very early into our relationship she shared with me about the tragic loss of her mom when she was 17 years old. Life went on as usual after her mom passed. In fact, many acted like nothing ever happened. She told me many family members on her mom’s side disconnected immediately after her mom died. So she suffered multiple losses at a time when she needed guidance and stability. Years into our work we began to understand that her bulimia filled the role of her missing mom and all the others who walked away. She was so afraid to connect with people that she unconsciously choose her bulimia as her best friend. We would talk about how “her eating disorder would never die or betray her.” Once we made that connection she was able to make a choice about having bulimia versus connecting to people.

Over the years it has become so clear to me that so many people stay stuck in their abuse or trauma as a way to not know. How do we accept things like, losing a mom at such a young age, or that my boyfriend who was supposed to love me also sexually assaulted me? How do we live with the loss of our childhood after abuse? How do we cope with the images of planes crashing into the world train center? There is not a simple answer to these profound questions. However what I bear witness to time and time again over the last 20 years is that if we allow ourselves to know what we feel and how our trauma affects us, we no longer need an eating disorder to cope with or not cope with the pain associated with these events.


Shari Botwin is conducting on-going podcasts for Mental Health News Radio. She is working on her second book, Conquering Trauma. To read her publications or listen to previous podcasts visit Her last podcast, Sexual Assault Survivors: Voices of Experience and Healing 04/25 by Mental Health News | Psychology Podcasts can be found here:

Shari’s next podcast will focus on the role of an eating disorder in staying stuck in trauma and loss. She will be talking with the host and another clinician about their personal and professional experience of working through trauma and moving past the ED. Shari will demonstrate how someone goes from surviving, recovering to thriving into a full life. 

For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.

Surviving Spring Break while in Eating Disorder Recovery

Angie Viets, LCP is an eating disorder specialist who has dedicated her career to helping her clients recover. In this week’s post, she discusses a common challenge for college-aged clients—spring break. Angie shares some tips on how to manage the stress of spring break while in eating disorder recovery.

Weeks leading up to spring break the refrain during therapy sessions with my college-aged client’s in recovery sounds like this, “Everyone, literally everyone around me is on a diet and losing weight to ‘prepare’ for spring break. And guess what I’m losing? My f’ing mind! How am I supposed to gain, or even maintain my weight in a world where it’s ok for everyone else to lose weight?”

The frustration is palpable and it’s real. Spring break while you are recovering from an eating disorder, is the equivalent to a recovering alcoholic walking down Bourbon Street during Mardi Gras. “It so sucks,” I say, “I get it; it’s messed up and unfair. I wish I could make it go away for you, but I can’t. So, let’s find a way to survive it.”

A few tried and true tips:

1. Personal responsibility
I learned in my own recovery that no one, I mean NO ONE can protect the sacred space of your recovery like you can. Of course, it’s hurtful when people you are close to continue to talk about their weight loss strategies even after they know you have an eating disorder. However, the reality is we are 100% responsible for our recovery. Period. Once that really sinks in it can be liberating (after you finish freaking out about it). Of course, you need tons of support along the way, but ultimately it’s up to you! And what I know about you, just like me, is that once our minds are made up, you better move out of the way.

2. Get in alignment
Purposefully staying in alignment with your recovery goals is huge, especially during high-stress situations! Here are a few suggestions to lighten the load. Meet with your treatment team a little more frequently until things settle down a bit. Listen to podcasts on recovery. Read daily affirmations that resonate with you. Follow blogs that are recovery oriented. Adopt a mantra to carry you through the next couple of weeks.

3. A visualization
Close your eyes and imagine being lovingly wrapped in a ball of golden light. This light gently warms your skin; it protects you. Your body, illuminated by the light, is a sacred space, a sanctuary where you are healing. The light creates a protective bubble around you that cannot be penetrated by the noise that once was so triggering. The noise never goes away; nor is it your responsibility to make it go away.

Honor the light by remembering that you have the ability to protect what you’ve worked so passionately for – Your Recovery.

4. Surround yourself with positivity
Choose the company you keep wisely. We don’t have the ability to change other people and what they focus on. We can, however, decide which relationships we invest our energy in. Consciously surround yourself with people who aren’t caught up in perfecting their body. (Believe it or not, they do exist; I promise). Love yourself enough to walk away from anything that makes you question your recovery. Your recovery tribe will believe in and encourage you. They will lift you up and nourish you. Be so grateful for them!

5. Be an observer
Notice that this flurry of activity around you is short lived. Sit back as though you’re a writer planning to tell the story of the “Spring Break Freak-out.” An observer story from a former client: “It’s starting again! All of my sorority sisters are ‘preparing’ for spring break by doing a Brazilian butt workout.” Years into her recovery she was able to see the absurdity of these trends and also recognized the sadness of feeling inadequate. She found it interesting to notice that as soon as spring break was over, so were those silly butt workouts.

When the volume is too loud around you and your brain feels cluttered with the competing agendas of recovery or commitment to your eating disorder, step outside. Notice that spring is here; which is truly a time of renewal. You are preparing for something a hell of a lot more important than spring break, you are preparing to Bloom!

Know that I’m thinking of you and am confident that you can ride the waves as they rise and fall. Be gentle with yourself. I’m so very proud of you!


For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.

Article Inspiration

Join us in reading soulful articles we have cultivated from across the web. If you have found an article you feel is inspirational, explores current research, or is a knowledgeable piece of literature and would like to share with us please send an e-mail here.

Mindfulness: A Path to Self-Acceptance Psych Central

Pain and Eating Disorders Denver Health 

A 5-Minute Meditation to Help You Find Your Calm Now Health

Cave Person Brain (Part II) Project Heal

To Be of Substance: A Personal Recovery Call to Action NEDA

If You Only Have Two Minutes to Meditate, Do This Mind Body Green 


For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.

Dual-Diagnosis Programming

In the field of eating disorder treatment, we understand that patients who seek care are typically presenting with ranging types and degrees of co-morbidities. Particularly delicate is the treatment of a patient who presents with both an Eating Disorder (ED) and a Substance Use Disorder (SUD). To meet the individualized needs of our patients who fall in this population, Monte Nido and Affiliates has developed specific protocols for addressing dual-diagnoses. At Monte Nido Newport Beach, the implementation of these protocols allows for specialized treatment of our dual-diagnoses patients.

Current evidence and expert clinical consensus suggest that integrative treatment of SUD and ED is the best model since both diagnoses are linked by common underlying factors that influence the stress response. Despite the many commonalities in a person’s experience of the two conditions, EDs and SUDs are different illnesses with different courses and treatment needs. When working with eating disorders we want to “remove the ‘–ic’” to help a patient understand they are not “anorexic” or “bulimic”, rather they had anorexia or they had bulimia. This speaks to the classically cited difference between the two illnesses, which is that abstinence from substances is possible, while abstinence from eating is impossible. With this in mind, we hold our belief that full recovery from an eating disorder is possible, while respecting that individuals remain “in recovery” from their substance use disorder.

The goals we set in our Co-Occurring Programming are driven by the aforementioned commonalities and discrepancies between eating and substance use disorders. The overall goal of treatment is to reduce rigidity and control over eating while increasing control over substance use urges. The initial focus of treatment is to re-establish a normalized pattern of eating and substance use sobriety. Once this stabilization has been achieved, the treatment team is able to help a patient narrow in on the transdiagnostic etiology, factors that maintain the disorders and common treatment targets. At this stage of treatment the team can help a patient explore trauma history, for example, a common underlying contributor to the development of both disorders. The continuum of containment encourages patients to develop increasing levels of accountability, self-awareness and capacity for tolerating distress. Since both disorders are driven by stress avoidance, our treatment plan is substantiated in decreasing emotional and experiential avoidance by encouraging people to utilize grounding techniques and healthy coping mechanisms instead of their disorders.

We are well equipped to contain substance use issues and integrate SUD treatment into the treatment plan for an individual who has a primary diagnosis of an eating disorder. If detoxification of the substance is indicated pre-admission, the patient will be referred to a detox program and transferred to a Monte Nido and Affiliates program directly upon completion. At almost all Monte Nido and Oliver-Pyatt Centers programs we offer a sober living environment and support both 12 Step and SMART recovery work. At Clementine adolescent treatment programs, co-occurring treatment is provided in both individual and family therapy. At the Partial Hospitalization Programs, our expert nurses provide additional medical oversight and safety of our patients who enter with Substance Use Disorder.

Monte Nido Newport Beach provides a specialized program for our patients who present with dual-diagnoses. Clinical Director, Kelly Souza, MA, PsyD is specifically trained in the treatment of Substance Use Disorders and has experience working in a substance abuse facility. She is currently working on obtaining her CADC certification and runs a specialized breakout group for dual-diagnoses patients. Additionally, Program Psychiatrist, Dr. Vicki Berkus, MD, PhD, CEDS, specializes in SUD and ED and provides on-site medication management. The expertise of our staff, combined with care that is tailored to the needs of each patient, allows us to provide the most effective treatment for individuals with a need for specialized care.

Monte Nido and Affiliates’ dual-diagnosis programming was developed based on the latest research and best practices by chief clinical staff with the intent to continue to provide outstanding care to diverse populations with the primary diagnosis of an eating disorder. As we further develop this programming, we will expand the specialized level of treatment offered at Monte Nido Newport Beach to more of our programs. For inquiries about the specialized programming at Monte Nido Newport Beach, please reach out to Regional Outreach Manager, Andie Hollowell at


For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.

Staying Power: How To Tolerate What Feels Intolerable

Jennifer Kreatsoulas, PhD, RYT is a yoga teacher and yoga therapist specializing in eating disorders and body image. In recovery herself, Jennifer is extremely passionate about helping others reconnect with their bodies and be empowered in their lives. Jennifer works with clients in person and via Skype. She also teaches yoga at the Monte Nido Eating Disorder Center of Philadelphia, is a partner with the Yoga and Body Image Coalition, and leads trauma-sensitive yoga classes. In this week’s post, Jennifer discusses the idea of “staying power” in tolerating what feels intolerable.

While on my healing path from anorexia I’ve had to learn how to tolerate what often felt positively intolerable (my body, food, treatment, calorie increases, exercise restriction, gaining weight, drinking supplements, painful therapy sessions, and much more). I was taught to sit with uneasy feelings and physical discomfort and to wait for them to pass. The reality is that that space and time of “waiting” can be in itself intolerable and set off habitual negative thoughts and behaviors. Yes, learning to be present to discomfort is an important life skill, and that awareness is key, however, I believe that approach can sometimes feel passive and leave us feeling helpless in a difficult moment or situation.

Staying power is what I call super-charged presence. It’s actively and directly taking on intolerable feelings — those feelings that set off negative thoughts and coping behaviors. It’s about staring those painful thoughts down and not letting yourself off the hook with sabotaging and destructive behaviors — like hiding food, over exercising, being dishonest with support people, or checking out by starving, purging, and bingeing. The more we practice staying power and get comfortable with what feels intolerable, then the door to acceptance and the deeper work of healing can open. But first, we have to learn how to NOT escape the feeling.

The minute you have the awareness that you want to dodge, push away, or ignore a feeling or situation is the exact time to tap into your staying power. In yoga, we have a saying: the pose begins the moment you want to come out of it. The same with recovery: the real work begins when we choose to stay and push ourselves to withstand what feels awful. In my experience, practices like mantra, deep breathing, and yoga poses cultivate staying power by creating focused positivity. For others, prayer, art, music, cooking, and nature brings a peace and calm from which to harness clarity and strength.

To learn your power source, reflect on these questions:

  • When in your life do you feel empowered?
  • What activity are you doing?
  • What thoughts, feelings, and emotions do you sense when you feel empowered?
  • How do you hold your body in that moment?

The qualities and activities you identified are your power source. To “stay” with what feels intolerable, you need to plug into your personal power source. It will both protect you from self-sabotaging behaviors and empower you to call on your strengths and not be defeated by what you believe you can’t tolerate.

I get that it’s not easy to REMEMBER your strengths when you feel consumed by an intolerable feeling and you want it to go away ASAP. Most likely, you have habitual responses that will need rewiring. To help you remember your strengths, I encourage you to create an intention that aligns with your power source or carry a grounding stone to help pull yourself out of ED Head and into the moment. You might even ask yourself “WTF” (What’s the Feeling?) when the urge to check out comes on or try this simple yoga practice to interrupt habitual eating disorder rituals.

Here’s the thing: we need to get creative and test out little tricks to begin to make small shifts in our recovery. We can’t cultivate staying power if we don’t actively, directly, and deliberately pull ourselves out of ED Head and use our personal power to rise above the challenge of tolerating what feels intolerable.

For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.

Three Reasons to Set Firm Boundaries and Enforce Them

Becky Henry is trained as a Certified, Professional Co-Active Coach (CPCC) and uses those skills to guide families to let go of fear and panic, learn self-care skills and become effective guides for their loved one in eating disorder recovery. In this week’s blog post, Becky discusses the importance of setting boundaries.


  1. They empower us and our loved ones.
  2. We gain time and energy to more effectively support our loved one in recovery.
  3. They keep us and our loved ones safe

    Boundaries are not cruel, they’re COOL!

It doesn’t help us or our sick child to fall prey to all of the chaos and fear of the eating disorder (ed). We need to live in-tune with our own desires, needs, and feelings.


If you love or care about or know someone who is in recovery from an eating disorder you may be feeling; fearful, helpless, overwhelmed, afraid, upset, and more. And if your loved one is over 18 you might fear there is nothing you can do to help them with recovery from one of these deadly brain illnesses. There is an endless list of things to fear; when they will eat next, when they might purge again, when insurance will cut them off, will they die?

Fear keeps us stuck. ​It’s time to ​send those fears on a hike!​ There is plenty you can do!

Make sure you’re included in the treatment plan!​ More and more treatments are including families so there is definitely a lot you can and will need to do. You may be wondering what you do if your area doesn’t have a program that includes parents at all. And perhaps your family situation is such that doing the FBT model isn’t a good fit. Then it’s a matter of finding treatment providers who will work with you and your loved one. Many treatment centers now include parents as part of the team and have options for learning how to help your child. Another option may be to go out of your area. If you’re in the USA, The Alliance for Eating Disorders can you help find a center that is a good fit for your child.

Educate yourself on eating disorders.​ The more you understand, the more competent and confident you will be in staying calm and not letting fear take hold. It will empower you and give you ​hope​ as you learn that there are effective treatments.

Treatment usually must continue for a long time, often even after they have been fully re-nourished for over a year. Please hold onto ​HOPE​, this is a normal part of the process.

Do your part to preserve your sanity and health, this helps you remain calm​ so you can actively preserve the relationship. Eating disorders can destroy relationships as well as lives. Remaining calm doesn’t mean it is going to be all wine and roses, but you can do your best to ​show the person in recovery that they are loved​ and protect yourself in the meantime by setting limits on what will will allow others to do to us. Not an easy task with someone who often thinks they are unlovable and has their thoughts distorted by the eating disorder. We don’t help them by taking on their experiences and ‘stuff.’

I know what I am in control of myself and my experience and that I’m not in control of other people and their experiences.

When we can be calm, emotionally objective and confident in our decisions we can then cope with the wild things the eating disorder will throw at us.​ Easy to say, hard to do. Keep reading, we’ll get you on the right path. You may need some extra support with this and that’s fine. We have parent support programs to help with that. Self-care is essential. It is not selfish! Doing things that fill you up actually helps you and your child.

Here is an example of a situation a parent might be facing:

“My child with bulimia also abuses alcohol and is stealing. I know he needs treatment for his eating disorder so I keep rescuing him when he shoplifts. I’m getting bitter and angry about constantly bailing him out with money but I’m so afraid if he goes to jail he won’t get the treatment he needs.”

The fear and lack of boundaries around what this parent is willing to set limits on are leading to them being taken advantage of and as a result, the child isn’t getting any better and the parent is becoming bitter and angry. This is not helping anyone.

We become so used to verbal abuse and disrespectful treatment from the eating disorder that we begin tolerating inappropriate behaviors. Once we come to grips with our ​fears​ and accept that boundaries aren’t cruel and punitive then we can begin to set limits. And reclaim our power and some ​HOPE.

I get it, setting limits takes time and energy that we don’t have. And in the long run, they give us more time and energy. Setting and enforcing boundaries are loving acts that keep our kids safe. It takes consistency to enforce them, especially when we haven’t in the past.

Remember having a 2 year-old that wanted to run out into the street? We didn’t let them even if they screamed or cried or pitched a fit. There is no way we would would let them endanger themselves like that. It’s no different now, the stakes are much much higher though. ​When we take the time and energy to set limits and enforce them, we gain so much time and energy as well as protecting our child.

It may better serve the parent in the example to instead of bailing him out say, “I will not finance your irresponsible behavior.”

We don’t want our child to live forever in an “almost anorexic” or “almost recovered” state as that would be much more painful and cruel in the long run than making the tough decisions to draw the line in the sand now.

Trust me, I understand how much it hurts. I will never ever forget flying across the country to take my child to treatment. I cried most of the way there and back. It was one of the most painful things I’ve ever done. It broke my heart into a million pieces. I get it how very painful some of the choices are that we have to make for our kids in recovery. These choices can save their lives.

Often with teens and young adults in recovery we must ​bravely use whatever leverage we have to set boundaries that keep them safe​. This might be letting them know the limits and rules for having the privilege of having a cell phone. Or using the car, or going to college. These are tough boundaries to enforce and they will most likely get angry with us. This means they’re learning they cannot use us anymore. Until we are consistent and stay firm they will continue to take advantage of us. And they often will continue resisting taking the recovery steps they need to take.

Boundaries can bring; HOPE, PEACE, CALM, HEALING and JOY!

For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.

Article Spotlight

Join us in reading soulful articles we have cultivated from across the web. If you have found an article you feel is inspirational, explores current research, or is a knowledgeable piece of literature and would like to share with us please send an e-mail here.


Substance Abuse and Eating Disorders NEDA

Garmet Project Offers Fresh Wardrobe to Those Recovering from Eating Disorders Trib Live

The Importance of Slowing Down Psychology Today

When You’re a Good Friend to Others But a Terrible One to Yourself Huffington Post

Do These Daily: The 3 Most Meditative Yoga Poses Mind Body Green

Using Mindfulness to Navigate “Self” Mindful


For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.

Treatment Now? That is the Question

Monte Nido’s Eating Disorder Center of Philadelphia Primary Therapist Kate Funk, MS, MFT shares some of her personal recovery journey in this week’s blog post. She explains that there might not be a “perfect” time to enter into treatment and to not let that stop you from seeking the support and help needed. Read on to learn more from Kate’s personal and professional experience…

Ambivalence is a common part of eating disorder recovery. Getting better can often feel terrifying and overwhelming which makes people question if they even want to recover. There is often a thick layer of denial and fear that can also make people question if getting better is truly worth it or if it’s the best time to start on the journey to recovery.

Many clients worry they don’t have time for treatment. (Financial worries, social obligations, academic pursuits, and upcoming vacations are just a few of the reasons clients have questioned whether or not to delay treatment.) As a recovered therapist I can relate to this issue on a personal level. I remember attempting to postpone my own treatment so I could attend my high school’s Homecoming. The woman looked me in the eye and said, “You might not make it to Homecoming if we don’t get you into treatment”. I was shocked. No one had ever spoken to me about my eating disorder like that before, but deep down something in me knew she was right.

It will never be the “perfect” time for treatment. There will never be a time in your life when everything is neatly tied up with a cheery red bow, you just happen to have extra money tucked away to spend on your well being, everyone in your life is supportive and excited for your recovery, and your “to do” list is empty. That’s not reality. Quite often, I find clients expect a variation of these scenarios in order to be ready for treatment. Treatment will never be convenient and, in fact, probably shouldn’t be. If recovery came easily the destination wouldn’t mean as much.

If you are wondering if you should go to treatment even though there are a laundry list of obstacles in your way, take some time to reflect on what’s preventing you from committing to treatment today. Ask yourself, am I truly present in my life? Am I able to laugh with family and friends? Am I able to concentrate in conversations? Am I able to engage in activities I enjoy? Is my life in jeopardy without more support? (This is a trick question; the answer is absolutely! Eating disorders are deadly!) Is it worth living a half-hearted life when I have the chance to recreate a whole one? Consider carefully your answers to these questions. Remember your life will still be there after treatment, and you might actually be present to participate in it instead of just surviving it!

Recovery is a process that allows you to peel away the layers of pain, break the habits and obsession, and heal so you can reclaim your true self. Treatment is the leap of faith that things can be better and the white flag admitting that your eating disorder’s way of life is no longer working. Asking for help is the most vulnerable thing we must do as humans, but it is also the most courageous. Treatment offers the opportunity to dust off and reclaim your life. If you are considering treatment, now is the time. Everything can be put on hold, but your health cannot. For more information on treatment please call our admissions department or email at

Honoring Client’s Self Determination: The Case of “A.G.”

Monte Nido & Affiliates Adolescent Treatment Program, Clementine Briarcliff Manor Clinical Director Danielle Small, MS, LMFT is an eating disorder expert who is dedicated to helping clients learn to accept their bodies and embrace their spirit while also connecting to their intellectual curiosity. In this week’s post, Danielle dives into the idea of treating clients who are resistant to care and touches on a recent legal ruling involving a woman suffering with Anorexia Nervosa. Read on to get Danielle’s insight into the topic…

Often in our work we encounter clients who are resistant to care.  They may only be in treatment due to boundaries held by loved ones and therefore may not be emotionally connected to letting go of their eating disorders on their own accord.  In these cases, we often speak of “meeting the client where they are at”; encouraging them to work on those aspects of themselves that they feel safe challenging, while we in turn build a case for full surrender to the treatment process.  Some of these clients eventually catch a glimpse of the value of letting go of their eating disorder and tolerating the unknown in order to live a different type of life.  Unfortunately, others don’t see the eating disorder as the problem, but instead the solution to managing whatever stressors they face.  So the question then is, when do we honor a client’s self-determination?  With the medical complications inherent to eating disorders, this can be a complex clinical question, fraught with legal and ethical concerns.

The idea of self-determination is central to the case of “A.G.”, a twenty-nine year old New Jersey woman suffering from Anorexia.  In November of 2016, A.G. was granted the right to refuse a feeding tube and instead she received palliative care.  On Monday, February 20th, 2017 A.G. died.  Her guardians and treatment team ultimately supported her decision to refuse medical help due to the toll forced-feeding and restraints would have taken on her body.  The judge in this case described A.G’s testimony as “forthright, responsive, knowing, intelligent, voluntary, steadfast and credible.”[1] This is not surprising, as many of our clients are incredibly bright, intuitive and capable individuals.  However, due to the often ego-syntonic nature of their disorders, they are not able to see past their own truth.

This post does not seek to argue politics or make judgments on the cultural implications of such a ruling.  It simply begs the question, how do we respond to resistance when it may be both final and fatal?  In cases where an individual is diagnosed with Alzheimer’s, Cancer or Parkinson’s, one would assume that the disease is seen as the enemy, not the friend.  Choosing to surrender to death is often connected to inevitable decline, financial hardship and the pain of invasive treatments.  If an individual were given an opportunity to heal, that opportunity most likely would be seized.  Yet with eating disorders the opportunity is often cast aside due to debilitating anxiety and fear, not to mention the discomfort of tolerating a body that feels like a betrayal.  How do we know as professionals when to let go and allow a client to walk their own path?  Do we advise the family to permit the client to connect to their healthy selves in their own time, or do we intervene regardless of a client’s wishes?

The standard in determining a client’s capacity is to assess the following[2]:

  1. Can the client communicate their choice?
  2. Can they understand the information relevant to making this choice?
  3. Do they appreciate the consequences of this decision?
  4. Can the client process this information rationally and in a way that is consistent with the client’s long-standing desires?

Many clients have no issues with points one and two.  However discerning whether a client is rationally processing the consequences of refusing care is the tricky part.

In A.G.’s case the court did not see the impact of the disorder on her cognitive functioning.  The judge saw an intelligent woman making a well-informed argument that further intervention would bring unnecessary pain and suffering. Clearly it was determined that the consequences were understood and consistent with A.G.’s well-established wishes.

I can’t speak from the perspective of a judge, but as a clinician, I aim to go beyond the standard assessment.  I certainly want to use all the empirically tested tools available to me, but I also want to connect to the essence of the individual; look into their eyes, hear their words and witness their suffering, whether that suffering comes from their eating disorder or the work of letting go of it.  I want to sit and process with those that love them, and for better or worse, have taken the journey with them.  I ultimately want to try to glimpse their soul self and tune into an intuition that cannot be labeled or quantified.  Only then can I make a determination on how I might chose to act if tasked with supporting or denying a client’s self-determination.


(2) Appelbaum, P. S., & Grisso, T. (1988). Assessing patients’ capacities to consent to treatment. New England Journal of Medicine,1635-1638.

(1) Kauffman, E. (2017, February 22). Eating disorder leads to court case, woman’s death. Retrieved March 06, 2017, from

(2) Schmidt, S. (2016, November 22). Anorexic woman weighing 69 pounds has a right to starve, court rules. Retrieved March 06, 2017, from


For more information about Monte Nido please call 888.228.1253, visit our website and connect with us on FacebookLinkedInTwitter, and Instagram.


My Soulful Journey: Grace Kuo

Monte Nido Rain Rock Lead Therapist Grace Kuo, MA, LMFTi utilizes her experience and clinical approaches in individual therapy, CBT/DBT group and Food and Feelings to work alongside clients towards recovery. In this week’s post, Grace shares some of her personal journey to joining Monte Nido and just what makes the Rain Rock team so special. Learn more about Grace and Monte Nido Rain Rock by reading her soulful journey…

What is your name and what are your credentials?

Grace Kuo, M.A., Registered MFT intern in CA and OR. I’m the Lead Therapist at RainRock.

Please give us a brief description of your background and what led you to Monte Nido.

I’ve always been fascinated in relationships and how to incorporate that clinically. I also believe in family work and seeing how relationships can heal the individual. Prior to being a therapist I was a personal trainer and got to work with women on how to feel strong in their bodies, which led to my interest in eating disorders and working on the deeper issues. In my work as a trainer, I also saw the distortions around food and weight. As a former collegiate athlete, I wanted to take my experiences and work with other athletes that may struggle with an eating disorder.

What does a typical day look like for you at Monte Nido?

A typical day for me can change. On some days I will have supervision, do sessions, have a recovery coach meeting, sit for a meal, then do group. On other days, I may go on a lunch outing with clients. I like that things at the residential level can change any minute and that we all work together as a team.

In your own words, please describe the philosophy of Monte Nido.

I believe that Monte Nido values person first. We see individuals as a human, and I think that has been a valuable part of my work with clients as well as my work as a clinician. Often times, clients see their identity in their eating disorder so helping them find their healthy voice to identify their soul self has been a beautiful thing to see.

How does your team work together? How do your roles overlap and differ?

I love this team. I think our roles overlap in the way we step in when needed and that we value each other with what each person brings to the table. I see how the four principles apply to our culture here to show up, be present, tell the truth without judgment, and don’t be attached to the results. I know I can trust each person who comes in and also provide different perspectives that we can collaborate together on.

Share a special moment/experience you had at Monte Nido.

A special moment I experience at Monte Nido is always graduations. It’s sacred in the way it honors the work as well as the relationships built. Sometimes it’s exciting, sometimes it’s sad, but I appreciate the moments that we can do this.

What is unique about Monte Nido?

I think the biggest thing is the belief in full recovery. I see it as something that provides a lot of hope and motivation, and better yet that clients can be curious about the type of recovery they want. It can be very empowering. I also appreciate the focus on relationships and how that heals the individual.

Share three facts about yourself.

I have an 8 month old Husky named Mochi, my parents came from Taiwan so I am fluent in mandarin and my brothers are 9 years apart but have the same birthday.


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