Ep. 260 Eating Disorder Care, Simplified: How to Understand Levels of Care and Find the Right Fit With Expert Jillian Lampert

Welcome to Behind the Bite, where we delve deep into the real-life struggles and triumphs surrounding food, body and weight. On Dr. Kristina Kastimini, a psychologist and certified eating disorder specialist, bringing you a unique blend of personal experience as they recovered individual with over 25 years of professional expertise. In each episode, we'll share the courageous journeys of individuals who have faced these challenges firsthand alongside insights from dedicated professionals in the field. Whether you're seeking healing, inspiration or simply a deeper understanding, this podcast is here to empower you on your own path to a better life. Join us as we explore stories of resilience, discuss the latest insights, and strive to foster a community of support and growth. Together, we can break down barriers, challenge stigma, and pave the way towards healing and living authentically. Hello everybody, welcome to today's show. As always, very excited to have you here, whether you are a first-time listener or you've been listening for a while. And I'm really excited for today's show because I think there are a lot of people who are confused about eating disorder treatment, and honestly, treatment shouldn't feel like a maze. But for most people, I think it does. Like, what level of care should I go virtual or in person, who's truly qualified? It's especially confusing if your labs look fine or your schedule is impossible or your insurance sends you to the wrong doctor or doesn't really talk to you. So we have a great guest today. I am joined by Dr. Jillian Lampert. She has 30 years in the field, lived experience of recovery, and is a national leader helping set standards for care. She is a VP at the Emily program and co-founder of Red Sea, which is a consortium representing eating disorder care in the United States, where she just helped launch a brand new plain language guide choosing eating disorder treatment in the age of hybrid care with the national alliance for eating disorders. Today, she's going to break down the levels of care, outpatients, IOP, PHP, residential, inpatient. I know, I just rallied off a lot of things, but don't worry, we're going to get all into that. We're going to talk about how clinicians actually decide what you need, why virtual care can match in person outcomes when it's the right intensity, and how to navigate real life barriers like school, jobs, childcare, location, and insurance without sacrificing your treatment or safety. We're also going to tackle missed medical red flags, weight bias, and the dangerous myth of, hey, I'm not going to quote sick enough. So if you or someone you love is standing at the edge of that cliff, like unsure of where to step next, this episode is going to give you a clear map smarter questions to ask, and a reminder that we both believe in is don't give up. Recovery is possible, and the right fit does exist, and there's going to be links to this new guide in the show notes, so I'm really excited to get Jillian. Okay, Jillian, welcome to the show. Thanks for having me, I'm excited to be here. I'm excited because I know a lot of people listening are going to get so much out of today. So just before we dive on in, why don't you tell us a little bit about you, your background, where you're at, because I know I did some intro before, but just from your own words. Yeah, so I live in Minnesota, I always like to start there. So live in Minnesota, I have been in the eating disorder field for 30 years, which seems wild to me, but in indeed is 30 years, I am a dietician by training my PhD is in nutrition with a public health and epidemiology focus, so I've done a lot of studying on eating disorders and disordered eating and big populations, particularly among adolescents, among athletes, a lot of looking into what can we do to possibly prevent disorder eating in youth, particularly have done some adolescent health fellowship additional training. So I just it's my whole career has been all about everything related to eating disorders. So my day job is a vice president at the Emily program, just a big treatment center in the US, and then as hobbies, I know people have hobbies that are like not related to their work, but mine are all directly related to my works. I am the president and co-founder of something called the Red Sea, which is the consortium representing eating disorder care in the US. It's so we do some policy work in Washington DC, we do a lot of standards work, we do a lot of collaborative work across treatment centers to make sure we're really continuing to increase the quality of care available for folks who need treatment from a needing disorder, and then I'm also on the board of the eating disorders coalition, which is the federal policy group based in Washington DC that does a lot with legislation and federal agency work to really try to make things better for people with eating disorders. So those are my sort of three big time occupiers, and I have a personal history of a needing disorder as well. So I come at this work both professionally and personally, when I was sick with a needing disorder in the late 80s or early 90s, nobody knew much about eating disorders, knew what to do, lots of people said lots of unhelpful things to me in the effort to be helpful, sure they were trying to be helpful, but it's really part of why I do the work that I do is to really try to make a difference for people so they don't have to feel so alone if they might be or are struggling with a needing disorder, and I am a mom and a partner and really consider myself an advocate for people with eating disorders and those that love them. Fabulous, and I'm relating to so much of everything, like just the 80s, 90s, there was nothing out there. It's kind so far, so thank you for all the work you're doing. It's so needed. Yeah, so thanks. So love to talk about something we were talking a little bit offline about that just what did you say came out yesterday? Yeah, exciting stuff that's so needed. So if you wouldn't mind talking about it, because this is like so exciting to me to hear about. Good, super exciting to us. So the Red Sea, again, that's the Association of Treatment Providers. We were hearing a lot from loved ones, from individuals, from providers in the field. We are hearing from all over the US, and we, our membership is really treatment centers of all kinds all over the US, and people were saying, I don't know what's happening, but people are really, it feels like people are really confused, and particularly in this day and age of, we came out of the pandemic, there's all this virtual care available, which is amazing. It really has, in theory, increased access to care. It's changed the way we all practice. It's changed the way people can access care. And so we're in this new phase of our careers, right, where there's really it's a hybrid, an age of hybrid care, because you can get care in person, you can get it fully virtually, you can get some of each. And we were getting a lot of questions from families, from loved ones, from patients, from people investigating care, from providers saying, like, how do I choose the right eating disorder treatment for me? I'm so confused because there's all of these ways I could get care. There's all kinds of different levels of care that I could get from a once a week kind of care with an individual clinician all the way up to a 24/7 care setting. And then there's all this virtual or in-person choice involved, and I'm confused. And so we were started to think about, how could we help folks be a little bit less confused or get a little bit more information. And then we contacted our colleagues over at the National Alliance for Eating Disorders, which is an amazing organization that provides a lot of support and virtual support groups for folks, tons of information and education for providers, and said, hey, do you want to partner with us on this? We'd like to make a guidebook. And so we did. We just launched it this week. And the guidebook is called Choosing Eating Disorder Treatment in the Age of Hybrid Care, a guide for loved ones, patients, and providers. And you can find it on the Red Sea website, which is RedC Consortium.com, and the Alliance for Eating Disorders website, which is AllianceForEatingDisorders.com. But it really seeks to give those groups, individuals who need care themselves, their loved ones, providers, some answers to most frequently asked questions that really aimed to answer that primary question of, is this treatment the right fit for me or the right fit for my loved one? So we're super excited that this guidebook is out there, and it's meant to be a handy resource written in sort of real person language that helps people to ask questions, to things to consider, is they are hearing treatment recommendations, and really walk through the process to be a handy guide for them. That's amazing. Like a private practitioner, I'm just going, oh yay, because it is it's so confusing, right? And I know it's scary, especially for families or loved ones. I think they're just so scared of, oh my gosh, am I going to choose the wrong thing? Or I just, I'm a parent myself, right? It's like you just don't want to choose the wrong thing. And I think there's just so much misinformation out there, too, of what treatment even looks like for eating disorders, because I think, especially in the mental health field, people don't really understand that like, you can't just go to any clinician to get treatment, right? It's not like in medical where you go to a specialist, right? You don't go to pediatrist if you're having a baby, right? They think, oh, I can go to any clinician to get treatment for an eating disorder, but that's not the case. And especially with insurance, a lot of times insurance will say, oh, you can go see this provider, but not really understanding like that provider may not be able to treat an eating disorder, but that's the provider that's covered. And so really understanding in that level of care, let alone, oh my gosh, wait, what's individual therapy to your point versus all the different levels of higher care. And so maybe we could even talk about that for someone listening going, wait, hold on, quit. There's different levels of care. What's happening? What is all that? Yeah, absolutely. I think you're right. Most people are like have probably more understanding of eating disorders through the pandemic. There was a lot written about it in the consumer media space around eating disorders. People know a little bit more. Lots written about mental health. Lots of increased awareness and maybe a little bit less stigma around accessing care for mental health. But what does care look like? And then the eating disorder world, because we have care depends on a range of kind of clinical factors for people. Right? Depending on the intensity of their eating disorder behavior, their nutritional needs. I have a particular interest in that as a dietician. But that's a unique piece of eating disorders. That's not as prominent of an issue in other mental health conditions. Like what's this person's nutritional status? And part of recovery for eating eating disorders is really so keenly related to their nutrition and what they need. So they need what's the intensity of their eating disorder behavior? What's their nutritional status? How are they medically? How are they psychiatric? How are they functioning? All of these elements go into determining what kind of care somebody needs. It's a pretty complex decision, right? That is a little bit more complex than some things that people might be more familiar with. Do I have this bacteria or not? So I get an antibiotic. Do I have this virus or not? So I get some sort of intervention. Do I have this? Is my bone broken or not? It's not as much of a yes or no. And so I think one of the key pieces to thinking about level of care is that there's no one size fits all solution. That eating disorder care does have a whole range of different treatment intensities because eating disorders come in a sort of range of intensities that require different care. So the levels of care really are those, there's five, right? In eating disorder care, there's outpatient where people are seeing maybe seeing an individual therapy therapist, maybe they're seeing a family therapist, maybe they're going to a group therapy session, maybe they're also seeing a dietician, maybe they're seeing a psychiatrist, maybe they're seeing a medical provider, but they have these like one to four people in their life that are their treatment team and they might see them all once a week. So you might spend an hour maybe up to three, four hours a week going to appointments. That's that outpatient level of care, right? But for a lot of people, that's not enough. So they need the next step on the ladder, which is that intensive outpatient program or IOP as we abbreviated an IOP as determined or described by the different regulatory bodies is a treatment program that's between nine and 19 hours a week. That really is based in the concept of a group based program. And we know as eating disorder professionals, the kind of the magic that happens in a group and the piece of sharing your experience with the needing to sort of with somebody else, particularly since eating disorders can lead people to feel so alone. Being in a group of people with eating disorders is just magic, isn't it? Where you sit in a room and you're talking about something and and somebody says, oh, I used to think that or I experienced that. Have you tried this or wow, I understand how hard that is. And that sort of group dynamic is so helpful in people's recovery. And so that intensive outpatient program is that nine to 19 hours a week. So maybe three hours a day, three, four, five days a week, where you're in a group with other people and you're also eating meals together, which that's really where that quintessential rubber meets the road with an eating disorder. As a dietician, I always say eating disorders aren't really about food, but they sure are about food when food shows up. So if food is showing up in our daily lives as healthy, free living people anywhere from three to four to five to six times a day, eating sort of sure can be a lot about food when the food is there. So how do we do that food thing together? But really building skills and building capacity to have strong coping skills to be able to have strong nutrition, to be able to really practice, develop and practice those recovery promoting skills. So that's that IOP three days a week, four days a week, five days a week for three hours. Then the next step on the ladder is usually called partial hospital program or PHP. Sometimes it's called day treatment, called different things in different states because of how states regulate it. But that is similar to IOP, group-based, lots of time with skill building and meals and all those recovery promoting skill development activities, plus your individual appointments. And that is just more time of the week. So now we're going from 19 to maybe 40 hours a week. So you're now in a treatment program maybe four or five, six, seven days a week for five to six to seven to eight or more hours a day. And that again is similar to that intensive outpatient program, just more, more of it. If that's then you move up the ladder to the to residential, which is 24 hours a day, seven days a week in a typically more of a home like environment or an environment where people have a lot of group-based structured programming and their individual sessions and are really practicing those skills, learning and practicing. I think recovery is really all about the learning and practicing. And then in patients that sort of top level of care is really when somebody is more medically or psychiatrically unstable and needs more medical or psychiatric intervention, needs more frequent medical or psychiatric care, needs more monitoring. So it's the most intensive level. So it's from the bottom to the top. It's outpatient, IOP, PHP, residential and inpatient. And I think it's key to let people know that sometimes people need to go up and down the ladder, just consecutively like that. Sometimes they pop around depending what they need. Sometimes they do a higher level care and step down the ladder. And then they have to go back up. And sometimes they do a higher level care and come back down and they never go back to a higher level care. And sometimes they start an outpatient and never need a higher level of care. And it's really important that people get what they need. That they get the care that's tailored for them because eating disorders are complex illnesses. And this is, like you said, this is specialty care with a multidisciplinary team. And it's not an elective service. Like this is a necessary health care service. So I think we're also dealing with, "Oh, do I have to? Is it really that important?" When these are illnesses that have the second highest mortality rate of any mental health condition. So yes, it's necessary. It's really important. Yeah. And I think that is the scariest part for me, too, is I worked at a hospital for a long time. And I'm sure you find this, too. As do most of the colleagues I talk to, it's like the labs always look stable. They tend to. And so there's this false sense of, "I'm okay. I don't need the highest level of care." But it's like this slippery slope. It goes very fast. And I think sometimes even like I talked to a lot of professionals as well. Like medical doctors tend to be the first place that people go. And medical doctors aren't unfortunately well-versed in eating disorders. And so there tends to be this false sense of understanding how dire things can get very quickly or understanding if your pulse is in the 40s. That's something to really look at. I don't know how many patients I've had that their primary care doctors or their pediatricians have not really read flagged that or seen it as something that, "Hey, we need to really take this seriously right now." And so when they come to see me, they're like, "Wait a minute." Like they're pediatrician. Their medical doctor didn't really think this was anything concerning. So why are you now saying, "Hey, we need to consider a higher level of care." Like I don't know if you find that as well. But. Yeah. We see that all the time at the Emily program. Somebody will call us at the Emily program and say, "Here's what's happening. And here's it by physician said to pollinating to sort of specialists and we do an intake over the phone and we get all this information and we say to the person based on everything you're telling us, we would recommend you be in the partial level of care, the partial hospital level care or residential or inpatient, whatever it is. And the person's so surprised. They're like, "What? I just wanted a therapist." Like you definitely need a therapist. Everybody with an eating disorder needs a therapist and you also need a bunch of other things. So that certainly can be surprising because you're right. Medical providers receive very little training in eating disorders. They receive training in lots and lots of things. But eating disorders is not one of them. And they're also, I think it's important to bring into the conversation there's so much weight bias and concern about weight in our society that eating disorders are so frequently missed that somebody might their weight might have changed or their eating behaviors have changed dramatically. But because they for whatever reason visibly look normal quote-unquote or don't look like anything's wrong, if their medical care doesn't involve diving into that or asking them questions. So when people call us and we say based on all these things, we think you need this high level of care. They're like, "No, I need to go to school or I need to go to work or I need to, I don't live near a treatment center or I'm not at all ready to think about doing that in a way that I think is, does them a disservice that we don't have better education in primary care offices or in pediatric offices? I know a lot of us across the country try to do more education in those offices. But I think it's important for families and individuals to know that, you know, just if they called a medical provider for something else and that provider said, "Here's what I think you need." That's what we're doing is eating disorders specialists saying, "Here's what we think you need." Not because we need them to be in that level of care, we put everybody in that level of care or one size of treatment fits everybody, but we really are making an individualized decision, which might be really different than what they're expecting. That doesn't make it less important or less true. Now I'm curious, you know, what you find as well because to your point, you just said, Oh, I don't live near a treatment facility or I can't leave work or I can't leave school if someone's saying the middle of a master's program that they are paying a lot of tuition for. They're really invested and they're almost done or they're a single parent with two kids in there, the primary provider. And you're saying, hey, you need to go to residential and oh, the treatment program that you need is two states away. Right? Like, how do you deal with that? And I've heard these stories a year after a year, right? And they're very difficult because it's again, like the mortality rate is a real thing. And yeah, life circumstances are a real thing. So maybe we can speak to that a little bit because I know maybe people listening are going, yeah, I need it, but. Exactly. And some of those life circumstances, like you're saying, are really difficult to be in it. And I will often tell people, I get it. I get what you just heard is a lot different than what you were expecting. And I try to help people to see put in a different context if you haven't for bed, got in a bad car accident. And you were driving to work and you got in a bad car accident and you found yourself in the hospital. And then your treatment team came to talk to you in the hospital and said, what you're going to need next is you're going to need X number of days or weeks in a step-down rehabilitative facility so that we can do physical therapy with you. And we can really help you recover from these injuries that you got in the car accident. We're so glad that you're going to be okay, but we really need to do this kind of treatment to make sure that you can regain your strength and your function. Right. Most people would be like, yeah, I, that's what I'm going to do. Most people wouldn't say, but I can't do that because I have ABC. And that's not to minimize it all what AB and CR like I get that people have families, they have jobs, they have all kinds of family and individual commitments in their life and they have all sorts of financial things that go into that. And I think the reason that that people respond differently when we tell them they're eating disorder requires a similar level of intervention as that car accident is that it doesn't feel as emergency to that. It doesn't feel as as urgent. It just feels a little bit like, no, I can do that later. And I think that's part of the illness, like having had the illness, I can get it, right. Like this illness convinces people that they're okay and really convinces people are tries to convince people that they don't need what these well-managed people are trying to tell them they need. And so when you have an illness that is trying to convince you or has impacted your brain to the point where your brain is not quite functioning like it would if you were healthy, it's going to sound like an odd suggestion to do all of that intensive stuff when it just feels like, can I just do something else? And again, back in that hospital, somebody with casts everywhere and needs to have lots of physical therapy isn't going to say, can I just go back to work tomorrow? Because for some reason, and I think it's related to stigma and probably lack of information, we think our mental health is something that can wait. And yet it can't. And to your point, eating disorders have a really high mortality rate. And I'm sure you have, as well as maybe very unfortunately, worked with people who thought they were going to be totally fine. And then they've had a really serious crisis where they've passed away from their eating disorder. And we don't know when that's going to happen. It's a very unfair part of this illness is that a long time ago, one of the physicians I used to work with at the hospital, I used to work with, described it to me, is it's like people are walking up to the edge of the cliff. And if they get to the edge of the cliff, they can very easily fall over. The really tricky part is we don't know where the edge is. We don't know where the edge is for that person. And I think about that a lot because people feel like, no, I'm fine, I'm not near my edge. And then they go over it. So that long story short, it's really I try to help people to see I get this doesn't feel like you were in a car accident. And now somebody's telling you have to do all this stuff. And that's what it feels like to your body and your mind. And that's why we're making that recommendation. And we wouldn't make it if you didn't need it. I think that's another interesting piece about mental health. Nobody in mental health wants to give people more treatment than they need. We really want to give them the treatment that they do need. Just like in medicine, nobody wants to give people more antibiotics than they need or more physical therapy than they need or more surgery than they need. We want to give people what they need. And so we're really invested in trying to help people to understand when you get those recommendations, it's based on what you need. And there also is a lot of support for the other pieces. Like we talked to a lot of people about FMLA leaves. We talked a lot of people about protected leave them. I'd be part of their state provisions. We talked to them about particularly college students like colleges are as scary as it seems. Colleges are pretty good at leave. They're pretty good at helping students take time off. Like they actually have whole processes for that. And so do high schools and so do middle schools and so do grade schools. There's a lot of support around education and needing to interrupt education so we can work with that. There's that some of that that protected support for employment. People's HR departments are generally really well equipped to help them manage a leave. And I know that some of the hardest parts can be child care or family obligations. And I often will talk with folks about I bet that you have people around you who would really want to help. People really do want to help. And we can help you to frame that for them. And what the ask is if your friend needed to go do something that left them without child care, would you want to help them? And their answer is almost always, yes, of course, people want to help. And so it's really around helping people to know it's okay to ask for help. Particularly when you have an illness that says, no, I'm fine. Yeah, that's that is so common to feel. These are I went through it too. There's a lot of shame with divulging that you're going through this to tell people. And there's that, oh, not really that sick or even people. There's a lot of us that when you talked about your feelings or opened up, you're like, oh, you're overreacting or you're too emotional, you might even have that. Oh, I'm just making a mountain out of a mohill or I'm it's not real or I'm not sick enough, especially if you've gotten messages like from anybody, oh, you don't look like you have an eating disorder. Like you can start to, oh, wait a minute. Do I really? This is a big deal. Like it gets scary. It does. It does. It certainly does. And it's easy to it really is easy to minimize and easy to feel like if this health provider told me something, that's one thing. But then I just don't see that echoed in my friends or my family or the media or it just feels so hard. And so I think it's totally valid for people to feel confused and to feel like there must be something else I can do. And I think that's a that's happens frequently. There must be something else which kind of is part of what brought us to write this guide that people were like, how about I just do a virtual thing? Like I can't travel or I can't all these other obligations make it really difficult for me to do what you're saying. But what about virtual? And that's what I think we want to be clear that virtual care is fantastic in so many ways. Virtual care has really changed the landscape for people that has made some of those things more manageable. If you're doing virtual care, then some of the travel time is different or some of the childcare requirements you might have are different. So it can definitely be possible as long as it's the right intensity, as long as it's the right fit for you. So it's really again about what do you need? And we really encourage people to ask a lot of questions, ask a lot of questions with treatment provider, ask a lot of questions about the illness, ask a lot of questions about why am I getting this recommendation? Because something like a virtual care program or maybe a hybrid situation where you do some in person and some virtually can be great. And again, the like one size doesn't fit all. It strikes me that we say that over and over again to our clients from a sort of body image perspective. One size doesn't fit all. There's not one ideal of beauty. There's not one ideal of attractiveness. There's not one ideal of what you should look like. Nor is there one ideal of what treatment should look like for everybody. One size does not fit all. So maybe you can do some other things and it still needs to be the right fit for you. Or at least the next best fit. If it's if the fit that you really need isn't available to you for whatever reason here insurance doesn't cover it or you just can't change your whatever life circumstances you can't manage those. What's the next best fit? Not just what's any fit. And it might take some time to figure that out and to find it and to really work to get all pieces in place. But it's super important to people's recovery journey because if they're in the wrong level of care if they're not getting enough care it just prolongs the time they have the illness. And you and I both know the longer you have this illness the harder it is the longer it is the journey to recovery that it the sooner you can do something the better off you'll be. And it's never too late to get care. So both of those things are true. Yeah. And I do feel like it's a fortunate time. Back in the day like I've been in this field a long time too. Like I would have never thought virtual care would be like beneficial. But now I'm doing it 100% and I have to say like I think there's so many benefits that I never would have imagined that I can't do in person like I can be with people in their homes. I think I was talking to you about this earlier. Like I can have real-time meals in their pantries in their fridges like it's amazing. I couldn't do that in they were in my office. There's some benefits too. And again, it's like there's options. And so I think to that point, there's a lot more that people can do that maybe they couldn't get benefits from before to your point. And because not everyone is eating disorder specialists, there's a lot more availability and access to care that maybe people could like especially in rural areas that couldn't get before. Yeah. Yeah. I agree. I have such a distinct memory of sitting with my colleagues at the Emily program in March 2020 saying we need to move everything to virtual, that's not a tool. 24-hour care program. How are we going to do that? And we did it in a week. And we spent a lot of time in one room together trying to redesign everything. We're like, how are we going to do meals virtually? How are we going to do group virtually? How are we going to do individual sessions virtually? How will we support somebody in a group meal when they're having a really hard time? If I were a person, I could go over to their chair and bend down and say, hey, I notice you're having a hard time or I could pull them into another room or I could approach them individually. How do I do that virtually? Turns out there are lots of ways you can do that virtually, right? There's like breakout rooms and chat and all kinds of things you can do. And you're right. I mean, as a dietician, I love that. I'm like, just take your camera over to your fridge, open it up, show me your whole fridge. We're going to, we're going to plant a meal right now. Like, I see, I see this, I see that, I see that. What do you think you can make with those? Show me your cabinets, show me where you sit and eat, show me where you store your food, show me your cooking, available space. There's so many things that were harder to really get a picture of. And we were working with our clients just in person. So I agree. I love the doors that virtual has opened for us. So I think that's fantastic. And I think it's really great from a recovery supporting. Like I said earlier, everybody needs outpatient. Everybody needs an outpatient therapist. I biased, but I think everybody needs an outpatient with an eating disorder. And so outpatient is a great opportunity to do that kind of virtual work because you can really get into the native gritty with people. And you can add those and make sometimes you do virtual care or part of your treatment as virtual part of it is in a person. That's awesome that we can do so many different things. The landscape is just changing. Now there's even virtual higher levels of care. And I don't know much about it. Maybe you know more. But the last conference I was at, I think they have what now you can, there's six scales without numbers that you can send the information to your treatment providers and get their vitals, which is amazing. Right. Yeah. Yeah. No, wait. That's, I think that's really amazing. We do, at the end of the program, we do virtual PHP. We do virtual IOP. We do virtual outpatient. We can do virtual nursing sessions where we do exactly that. We can get somebody's weight. We can get somebody's vital signs. Maybe it means we've sent you a blood pressure cuff and we on on camera together or help you make sure you're getting your blood pressure correctly. It's amazing what you can do at home. And also what we do now medically, right? Like the medical whole medical establishment has this due tons of stuff at home. Your dermatologist can be like, show me that rash on the side of your face. Just put your camera right up there. So it's some of that same stuff that is enabled virtually, but I've really been clinically amazed like as a clinician surprised. And also with my user research hat on, the data are good. The data are really good when we look at the data that compare a virtual, let's say a virtual partial hospital program to an in-person partial hospital program, the data are pretty good. And they, we really can be effective 5, 6, 7, 8 hours a day on a virtual platform to deliver PHP care compared to in-person. And everybody's though there's certainly factors in who does who does better who does well or less well in a virtual program versus in in-person program, but it is impressive what we can do. And so I think that the degree to which that was developed in large part because of the pandemic and really accelerated because of the pandemic is impressive. That would have taken the field, I don't know 10 or 15 years to figure out how to move some of those things virtually. And it took us 10 or 15 days in a short period of time to do that. And I think it's awesome the degree to which we've been able to expand access to care. But there's also all these, I think these sort of myths that people or things people hear about, some people hear, "Oh, I've heard virtual programs are more, they're more tailored or they're more personalized or in-person care is more restrictive than virtual care." And I think that those are not super accurate. I think that good eating disorder treatment, as we would probably both readily agree, is personalized care. It's based on what you need, like what kind of nourishment you need, what kind of coping skills you need, what sort of interventions with your sleep you need, what sort of support you need with your movement, what sort of support you need with your emotional regulation, all of those pieces that care should be personalized no matter what level of care you're in and no matter how you're getting it. If you're getting it virtually or in person or if you're there 24 hours a day or you're there once a week, care should be designed for you. And so I think that's really important for people to remember that they're involved in their care, that this is a kind of treatment that really needs input from the person. Just like your physical therapist asks you, "Does it hurt when you do this or can you do this?" This kind of care also requires a lot of input from the individual with the illness. Right, because I would imagine some people really need to be away from their environment, away from their stressors, a way to just really focus on themselves and be somewhere else without maybe some of the external things that are contributing to maybe what's going on. Some people might not do well with virtual at all. So, again, to your point, it's very individual. And I'm curious, is there any discussion in the guidelines about how to choose a higher level care based on lots of eating disorders are promoted with like trauma or depression or anxiety or even specifics to like binge eating disorder versus the anorexia nervosa or bulimia nervosa? Does there discussion about how to choose a facility that's pretty specific to what they're going through? Yeah, I think there's a number of different levels of specificity in it. First is that it's really a level of care. We have it on our also on our Red Sea consortium website. We have this sort of description of levels of care because people often don't even know what those are. What does that mean? What's a level of care? So we have these nice definitions of levels of care. And then we also have the level of care criteria like how do we as clinicians decide what kind of level what kind of care somebody needs? And we do have a pretty pretty strong agreement as a field around what the what constitutes intensity of symptoms and intensity of eating disorder and other other factors like comorbid conditions or other co-occurring illnesses, degree of support and frequency of eating disorder behaviors, some medical pieces, right? There's a lot of aspects to to that decision tree that leads us down the path till here's what we're recommending for you. And we have that level of care criteria on our website too that that really is the summary of what the field has written about and published about and all over the major organizations that write guidelines contribute to that sort of thinking. And we all as a field I think have a pretty good agreement on. Yeah, if you have ABCD and some E and F, then you're going to need an intensive level of care maybe an inpatient or residential. And if you only have E and F, then maybe you can do outpatient. And if you have B and E and A, then maybe you need a partial hospital program. So it really helps people to understand like what are they going to assess when we say we're doing an assessment? What are we assessing? So the guide as well as some of the other pieces on the Red Sea website and on a lot of eating disorder program websites have have out here's what this care is and here's when people need it. But I think that the basics of that are really around how disruptive, intrusive is this behavior in your life and how frequently does it occur, how much brain space does it take up when you talk to people who are really struggling with an eating disorder and you ask them how much of the day do you think about food or weight or shape or eating. And a lot of people say more than 100% because they dream about it. And that that's a really high level of thought consumption by an illness where somebody else might say oh it's really kind of wrecks a couple hours of my day when I have to decide what to eat or when I get really upset or when I feel really out of control with my emotions or I feel like I don't have the support I need. So I think that's why we do that assessment and I get's key to highlight. We ask all these questions in an eating disorder, even the preliminary intake because we really want to match you with the right level care. And so I think those are the things that people should expect. Like we are going to ask about other things. Do you already struggle with anxiety, with depression, with co-occurring PTSD, with trauma history, with OCD, with what's your support level at home? What's your home environment? Like what kind of support do you have to get better from this illness? And what are the things that might be complicating as we help you to get better from this illness? So I think it's not a sort of clear cut path that we can tell this is what it looks like exactly for every person, but it really is again that specialty care that's based on the needs of that individual and we can only determine that when we ask that person a lot of questions, which can feel really invasive and uncomfortable for people. Like you said earlier eating disorder stuff is hard to talk about and hopefully we're doing a good job as providers to say I tell everybody I've ever done an assessment with I get that this is hard to talk about. I get it. I didn't want to talk about it either and I also get that maybe because a needing disorder is really hard to talk about, you might not be able to tell me kind of everything and that's okay that we're going to spend time together and over time I'm hoping that you'll be able to tell me more but I want to get it as good of an idea as you can give me and the more I know the more I can help and the less you tell me the less I can help. So I really encourage people to even though they might not know us at all or very well to really try to take that leap of faith to trust that we at least we might not know them but we know these illnesses and they have a unique story and these illnesses have a lot of commonalities between them and we're going to really use our experience with the thousands of people that have come before them to help them get what they need. Now that's well said I'm so glad you did mention that because it's scary. And so anyway, when listening just realize there is help out there and yes, there's a tendency to lie or hold back. That's so normal. But it is. And I've both been there and get it. Totally. Like I get it. Why would you tell? I'm a stranger. Why would you tell me all your inner secrets right away? I only want you to tell me because the more I know, the more I can help. And I want to earn your trust. I want to build the conditions in which you feel like you can tell me that. And the more you can give me, the better I can meet you where you are. So I think it's important to really keep that in mind too. That if you've told somebody something and they're like, okay, this is the level of care we think you need. And you might be thinking like, oh my gosh, I'm not that sick. There's that's not the right thing. Or wow, there's a bunch of stuff I didn't mention. I wonder what would happen if I did that to really try to trust again that we are trying to match what you need with your illness. Just if you had a broken bone, your physician is going to try to match the intervention for your broken bone with what your broken bone situation is. And if you don't show them your broken bone, it's a lot harder for them to treat you. That's why we're asking all these questions about eating disorder. Yeah, absolutely. I'm so glad you're Ruthies. I'm so glad you're talking about this. Oh my gosh, Julian, you're doing such great work. I'm just thank you. Yeah, it's come so far in the decades. And just it was people like you that are like moving everything forward. So thank you. Oh, so I will have everything that you shared in the show notes. So anyone who wants to go there and find all of the resources, they will be there. Anything you want to end with for people who are listening? I would say I ask folks who experience to have a personal experience of an eating disorder. I always ask them like, what would you say to somebody who was listening to you? Who might be thinking like, yeah, that's fine. That's great. This all sounds fine. And what it's not going to work for me. And so I just want to put that out there that I really would tell anybody listening that feels like, I don't, whatever your guide says, that's not going to be helpful for me. It's like recovery is not really possible for me. It is. It absolutely is. It 100% is. And don't give up that that's the I think the most important thing in this whole career of mine that I've had around working with people with eating disorders like you can't give up. You just got to keep going. If it takes 11 times and we stop at 10, we were so close. We're not going to give up. And I think you want to, I think it's part of why we wrote this guy like we want people to not give up on themselves and we're not going to give up on people. We really want people to keep trying. And we're going to be there right next to you. Just like you are with everybody you help, right? We're going to be there with you because we know it's possible. And it's recovery is a lot better place than the eating disorder. No, sad. I love that message because I hate that myth that you can't recover. Yes, and yes. All right. Thank you again so much. It's been a pleasure having you. You're welcome. Thank you so much. Thank you so much for listening today. Behind the bite podcast is created by me, Dr. Christina Castanini as part of the Los Angeles Tribune podcast network and produced by the Twicky Tales. I love hearing from my listeners. So if you like the show, please rate and subscribe to it on whatever platform you're on. And for anyone who wants to understand their relationship with food better or who might be wondering if they have an eating disorder, I have a free nine week e-course at my website. Just go to www.behindthebitepodcast.com to get your free e-course today. Please note, this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither host, the publisher or the guests are rendering legal, clinical or other professional information. If you want or need a professional, you should find one to work with who can address your individual needs and situation.