IMT for Eating Disorders: Should I Use Regular or Appetitive Eating?

IMT Question: "Should I use regular eating or an intuitive/appetitive approach with my patient?"

IMT Response:

The answer is both! Rather than viewing regular and intuitive/appetitive eating as opposing methods, we have integrated these approaches into a module called Regular and Appetitive Eating (RAE). You can find the guidelines on administering Regular and Appetitive Eating (RAE) in, Treating Eating Disorders in Adolescents, along with a series of free handouts/worksheets for the patient in the accompanying PDFs.

In short, the guidelines in the book recommend that regular eating first be established with the use of food logs etc. Once generally appropriate quantities and varieties of food are being eaten, patients begin to to develop the skills required to detect the appetitive cues of hunger and fullness (e.g. mindfulness). Once these cues can be detected, patients experiment with eating in accordance with the cues.

In Regular and Appetitive Eating (RAE), patients are instructed to eat meals within general windows of time (e.g. 7-8:30am, 12-1:30pm, and 6-7:30pm) as well as in accordance with their appetitive cues of hunger and fullness. Snacks work similarly.

Regular and Appetitive Eating (RAE) is one of six different modules presented in the larger Integrative Modalities Therapy (IMT) for eating disorders, described in the book. RAE is presented as part of individual therapy along with interventions for improving body image. There are also interventions for group and family therapy in the IMT collection.

Below is a photo of one of the RAE Handouts.

If anyone has any questions, please feel free to reach out!

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IMT for Eating Disorders: Does Removing Body Checking Triggers Foster Body Avoidance?

As the doctoral students I supervise ask questions about Integrative Modalities Therapy (IMT) for eating disorders, I'll be addressing them in the Community of Professionals for Learning IMT group on Facebook. For a short period, these articles will be posted here as well.

Student Question: "Isn't removing triggers for body investigating/checking (e.g. covering the mirror) fostering body avoidance?"

Response: You can combine the techniques of removing triggers with body exposure exercises. For instance, having a patient cover mirrors at home towards the end of decreasing body investigating, does not mean that an additional body exposure exercises cannot concurrently be added to treatment. It is possible to both conduct in-session in vivo body exposures by looking in the mirror as well as assigning the homework of looking in the mirror for 5 minutes at home once per week.

In IMT terms, this means that you can teach the ROCKS skills for Body Investigating while also conducting in-session in vivo exposures as well as assigning them for homework.

Please feel free to join our private community of IMT professionals on Facebook! Building a sense of community is essential to collectively tackling these illnesses.

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An Interview with IMT for Eating Disorders Author, Tara Deliberto PhD

In preparation for pub day on 8/1, I did this interview with my lovely agent, Carrie! Here is the article she posted on her website below.

-Tara Deliberto, PhD

Pub Day Interview!

Tell us a bit about you and what you do.

Sure! I'm a psychologist with a job that looks different than what most people might imagine. I work at NewYork-Presbyterian Hospital with people diagnosed with eating disorders who currently need what is referred to as a "higher level of care" (e.g. inpatient hospitalization). Rather than attending therapy once per week, the patients with whom I work need care every day at a hospital from a specialized multi-disciplinary team to foster both physical and psychological recovery from eating disorders. Several years ago, I opened and directed a "partial hospitalization program" or PHP where adult patients come in for treatment from 8:00am-3:00pm, Monday through Friday. This program offers patients an opportunity to either step down from inpatient care or prevent hospitalization.

Currently, I am an assistant professor at Weill Cornell Medicine, the medical college of Cornell University, working in the program at NewYork-Presbyterian that I created, training advanced doctoral students as well as post-doctoral fellows. In this role, I teach an eating disorders seminar at the hospital that all staff members and students at the hospital are welcome to attend. While carrying out my roles as a hospital psychologist, administrator, and teacher, I worked on creating a new treatment approach called Integrative Modalities Therapy (IMT) for eating disorders along with my colleague, Dina Hirsch, PhD.


How did you put together the research for this book and what made you realize that you should write it?

Ironically, I spent my first four years of training with the thought "I want to treat everything but eating disorders because they’re just too difficult." I know a lot of clinicians think the same. But when I saw the state of things, I felt entirely differently. In fact, the treatment landscape for people with eating disorders – the deadliest of mental illnesses - was so bleak that felt compelled to devote my career to improving the quality of care. I knew that clinicians used to think, “I want to treat everything but borderline personality disorder because it’s just too difficult” until Marsha Linehan, PhD, created Dialectical Behavior Therapy (DBT). Then, clinicians started enthusiastically treating borderline personality disorder because they loved learning DBT. It was clear that someone needed to do the same for eating disorders.

The journey of creating IMT started years ago when Dina Hirsch, PhD, was my supervisor at a partial hospitalization program for adolescents with eating disorders at NorthWell Health. I was fairly new to the treatment of eating disorders at the time and was shocked to find that there was simply no evidence-based treatment material written for use with adolescents with eating disorders. The modus operandi at the time was to use repurposed material for adults with other disorders such as anxiety or borderline personality disorder. I remember saying to Dina: "we have to do better than this!" She agreed. Later that day, we were in a required meeting and I passed her a note with the sketched out plan for IMT I had been mulling over since the prior year. Unlike anyone else I told about this idea in the past, Dina immediately encouraged me to follow through with it.

Right away, we started creating group material rooted in either previously published evidence-based treatment manuals or one-off interventions described in research papers. We also started writing similar material for use with parents/carers in our family meetings as well as with patients in our individual therapy sessions. Over time, the collection of interventions – what we now called Integrative Modalities Therapy (IMT) - amassed into three separate works for use in groups, family sessions, and individual therapy.

Others in the field started to express interest in using our materials. Some clinicians even started translating them into other languages for use with their patients. This type of feedback quickly signaled to us that we had been creating a flexible and scalable treatment for eating disorders in adolescents that others perceived as rather easy to administer in both hospital and outpatient settings. It also became apparent that IMT could be used as a tool to train clinicians in geographical regions where eating disorder specialists were sorely lacking. I then started to think that maybe this could be the treatment that interested clinicians in eating disorders. Understanding the potential for IMT to help, we set out on a mission to see it published and disseminated, hoping to contribute to the efforts made by those in our field to improve care.



What makes the type of treatment outlined in your book different from what is already out there?

IMT is rather different than what is out there for several reasons, some of which are likely surprising. As mentioned above, IMT is chiefly different than what exists in that it includes handouts/worksheets steeped in evidence-based treatments for adolescents. To our knowledge, nothing like this existed before IMT. It is also different from any other type of manualized treatment we know of in that there are interventions designed for three separate types of therapy settings: individual, group, and family therapy. Lastly, unlike other treatment protocols, IMT is designed to be used very flexibly. Each handout contains an intervention for a specific issue a patient may or may not face. As such, each patient gets a different set of treatment materials depending on what they need.



Relatedly, IMT is different in that the material can be used flexibly in inpatient settings.

Yes! Absolutely. Specifically, IMT is rather different in that it was created for use in inpatient, residential, and day treatment settings, as well as in outpatient settings. Most treatment manuals seem to be written specifically for use in outpatient settings. Due to factors such as the medical precariousness of our patients, however, many people with eating disorders are treated at higher levels of care (e.g. hospitals, residential programs, etc.). Considering that 1) other manuals are written for use in outpatient, and 2) a large and important portion of eating disorder treatment is delivered at higher levels of care, there was a big disconnect between what was available and what is needed. For instance, when an adolescent with anorexia nervosa is healthy enough to be in outpatient care, family therapy is absolutely essential. The outpatient manual, therefore, prioritizes interventions with the parents/carers. At higher levels of care, however, the patient is attending treatment groups all day with peers. Patients, therefore, need standardized evidence-based materials to be administered during those times.



Are eating disorders diseases that easily are ignored or dismissed by their sufferers or their families?

Both people with eating disorders and their families are often completely unaware of the illness. Eating disorders are different than most other types of mental illnesses in that they are considered to be “egosyntonic.”  Generally, this means that a patient does not present as wanting to recover from the illness. Food restriction, for instance, may be viewed by patients and//or their families as “healthy,” rather than as part of a life-threatening mental illness. As such, people with eating disorders may present as being unmotivated or unwilling to change behaviors they perceive as healthy. Similarly, family members may also present as unwilling to aid a person with an eating disorder in recovery if the perils are not fully understood.

Other patients and family members, however, do recognize eating disorder behaviors as problematic, but do not feel equipped to address it for variety of reasons. For instance, when confronted about the illness (e.g. a family member prompts more food to be eaten at a meal), a person with an eating disorder may have an explosive reaction, resulting in the family member drawing the conclusion that “it is not helpful to interfere.” In IMT, a behavior that is aimed at / results in others withdrawing support (e.g. having an explosive reaction), is referred to as an “eating disorder protective behavior (EDPBs).” Despite knowing that a problem exists, family members can become conditioned to ignore the eating disorder when people engage in EDPBs. Without having the skills to address the problem nor knowledge of how to access resources, many family members simply abandon efforts to intervene, feeling helpless.

Especially considering the variety of factors preventing people with eating disorders and their families from recognizing and/or addressing the illness, it is up to clinicians to know that eating disorders are life-threatening illnesses that require immediate psychological, psychiatric, and medical treatment. Of note, eating disorders are much more common than even ten years ago. In fact, a recent study showed that the number of eating disorders cases has doubled in recent years (Galmiche, et al., 2019). Research is also is showing that people of all genders, ethnic backgrounds, ages, and socio-economic statuses have eating disorders. In short, because eating disorders are 1) ego-syntonic, 2) life-threatening, 3) have a rapidly increasing incidence, and 4) impact people from all backgrounds, we strongly recommend that all people presenting for therapy should be screened for eating disorders.


Can you tell us a bit about IMT and its mission?

With IMT - a curated collection of evidence-based interventions – we aim to help patients develop skills, support families, and provide a way for clinicians in the trenches to communicate core treatment concepts. We also hope to attract new clinicians willing to treat eating disorders, so that more treatment options are available to patients. In short, our mission is to help close the treatment gap.

Integrative Modalities Therapy for Eating Disorders

Back in March of this year, the approach that Dina Hirsch, PhD, and I created for the treatment of eating disorders was renamed Integrative Modalities Therapy (IMT)!  Here I'll explain the reason for the change as well as the meaning of the new name.

When we started out, our aim was to create a comprehensive collection of evidence-based interventions for patients and families with eating disorders.  For the original plan, we knew that we needed to have an approachable patient-and-family-facing name.  We decided to call the first version of our book "BITE," or Behavioral Interventions, Tips, and Evaluations.  At the time, this name was fitting since the acronym represented the smallest behavioral step a person can take towards recovery (i.e. taking a bite of food) and the fully spelled-out name descriptively explained what was included in the book. It was a go!

Over the years, however, our singular book that brought together interventions, tips, and assessments grew into something much larger: an evidence-based practice treatment approach.  We soon needed to write a treatment manual for clinicians to use alongside the original book for patients and families. Our unpublished manuscript became a resource for clinicians in the trenches who needed a summary of all of the varied evidence-based interventions in one easy place.  Some have called our approach "evidence-based practice in a box."  Recognizing the potential of this type of resource, our goal became to provide clinicians with a comprehensive, practical, flexible, and scalable resource to help navigate the treatment of eating disorders. 

Considering these advancements, prior to both books being published by New Harbinger, it was time for a new clinician-facing name!  We chose to rename our approach Integrative Modalities Therapy (IMT) because it integrates a wide array of evidence-based interventions from gold-standard treatments into the three modalities of individual, group, and family therapy.  In short, the approach is both integrative and can be administered modularly across the three treatment modalities.  As a clinician-facing evidence-based practice approach, we now have the big, hairy, audacious goal of contributing to the efforts of our colleagues by helping to close the eating disorder treatment gap together.

IMT Resources will be Available through Amazon and the New Harbinger Website

Hi there! If you happened to have pre-ordered an IMT Client Resource Book from Amazon, you will likely be receiving a notification regarding reimbursement. New Harbinger is restructuring the way the books will be sold. The IMT Clinician's Manual *will* be printed and for sale on Amazon through New Harbinger. Conversely, the Client Resources will be sold in PDF format for a nominal price to clinicians via the New Harbinger website starting on 8/1! Thank you so much for your continued support. We're very excited for the IMT material to be publicly available in less than two months!

Evidence-Based Practice for Eating Disorders and IMT

We are weeks away from the IMT books being formally published by New Harbinger on 8/1! In preparation, we thought it would be helpful to describe the unique "evidence-based practice" approach that IMT takes.

So, what is an evidence-based practice (EBP) approach? According to Sackett et al. (2000), EBP is the mindful use of the currently available evidence to inform decisions about the implementation of treatment for an individual patient. It includes the following three components:

1) a thorough search of and critical review of the available evidence,

2) a clinician's own experience and expertise, and

3) the preferences of the individual.

The IMT books formalize the EBP process into a written format, with the goal of informing clinicians about how eating disorder specialists may treat various presenting problems. These books are a collection of evidence-based interventions compiled into individual, group, and family therapy modalities, that were - until now - scattered across academic journals and only used by practitioners in-the-know. In short, IMT aims to inform clinicians who do not have such highly specialized training/experience about what the pros actually do in the trenches. Considering the serious lack of training clinicians across all mental health disciplines receive on the treatment of eating disorders, the deadliest of all mental illnesses, it seems to us that this type of practical and informative EBP approach is sorely needed.

Being that IMT takes an EBP approach, the manual is not a rigid protocol that has been investigated by many independent researchers; instead, it is a reflection of what clinicians trained in evidence-based approaches might do in practice, given specific circumstances and patient needs not accounted for by existing protocols. This kind of approach inherently provides the clinician with flexibility and autonomy regarding which interventions to implement, depending on the needs/preferences of the individual patient. As such, there is both a standardized set of interventions in IMT as well as the ability to individualize care for the patient by administering them selectively. In addition to its standardization, flexibility, and ability to be used in an individualized manner, we hope that IMT will be scalable, meaning that it can be easily learned and implemented in practice.

Borrowing a business term, our big hairy audacious goal (B-HAG; yes, that's an actual term) was to create a standardized, flexible, able-to-be-individualized, and scalable treatment with IMT to help with filling in a deadly treatment gap. Considering the step-by-step format of the manual, it has been described as "evidence-based treatment in a box." We aimed to write a manual that benefits both trainees and clinicians in more remote areas of the country/English-speaking world as well as patients and their families.

For updates on the IMT project, sign up at: http://bit.ly/2MiijBQ.

The Importance of Accepting Recovery

Imagine the following: no matter what you do to try to change your body size, shape, and weight - whether it be diet, exercise, or liposuction - it instantly returns to exactly the way it is now.

What thoughts and emotions does that scenario bring up for you?

For some people, this exercise immediately prompts feelings of anxiety and loss of control. Some can be so provoked, they immediately shut down the experience by logically poking holes in the scenario such as “this couldn’t be real, so I don’t feel anything because I know I can control my body.” For others, relief from the constant struggle with their body will be felt. After all, if nothing can be done to change something, you might as well start accepting it, right? Only those who truly accept their body will be left unmoved by the exercise.

Beyond an interesting thought experiment, this exercise is an important Integrated Modular Therapy (IMT) tool on the road to recovery. This post explores some reasons why.

In eating disorders, recovery itself is feared and avoided. People with eating disorders have a fear of fatness and recovery is equated with fatness. As such, recovery is feared and behaviorally avoided through the engagement of eating disordered behaviors (e.g. calorie restriction, food avoidance, binge eating, intolerance behaviors such as purging, etc.). Because recovery is feared and avoided, imagining what it would *really* mean to be recovered is an interesting avenue for treatment.

In essence, the recovery entails: 1) refraining from engaging in attempts to change the bod, therefore, 2) experiencing a variety of negative emotions and other internal experiences (e.g. physically feeling full), and ultimately 3) coming to accept one’s body in the absence of attempting to change it. As such, exercises like the one above are designed to engender these experiences.

Because people with eating disorders can be unwilling to totally abandon eating disorder behaviors (i.e. attempts at changing their body), positing a world in which they cannot change their body prompts acceptance through the experience of learning to tolerate negative experiences crucial to recovery (e.g. loss of control and refraining from behaviors) that would otherwise be avoided. As such, this exercise primary serves as an imaginal exposure exercise.

In addition to prompting patients to learn to cope with negative emotions about recovery, this exercise often engenders positive emotions. For some patients, the participation in this exercise is the first time they really experience any sort of relief regarding the absence of eating disorder behaviors. Experientially knowing that abandoning the eating disorder behaviors can be a relief is very salient for some.

In summary, from an Integrative Modalities Therapy (IMT) perspective, the healthy alternative to trying to change the body is active acceptance. Acceptance can be fostered by identifying what is being avoided (e.g. particular aspects of recovery), then engaging in a crafted exposure to those negative stimuli.

Conducting Mindfulness Exercises in Eating Disorder Treatment

by Tara Deliberto, Ph.D.

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If you have never conducted a mindfulness exercise before, it can be difficult to know where to start. This post is intended to walk you through the various steps involved in conducting a mindfulness exercise in session.

First, prior to conducting an exercise, it is helpful to try some out on your own. Perhaps try downloading a mindfulness app for assistance. I recommend doing one 3-5 minute exercise per day for a couple of weeks. Be sure to check in with yourself after the exercise and note your internal experiences. What are you thinking? How does your body feel? What emotions are you experiencing?

Next, you’re going to need a Tibetan singing bowl. A small one is fine. They can easily be purchased online or in spiritual shops. Once you have your bowl in hand, practice ringing it. If the mallet has a felt tip, hold the mallet by the wooden portion. Practice lightly hitting the felt side of the mallet on the side of the bowl.

Once you’ve practiced mindfulness and using the singing bowl, it is time to start rehearsing conducting an exercise. Select a mindfulness exercise (e.g. leaves on a stream) that is about 3-5 minutes in length for clinical settings. Then follow these steps:

  1. Ring the Tibetan singing bowl three times to start.

  2. Wait for the third bell to stop ringing then begin.

  3. No matter what type of mindfulness exercise you're doing, it can be helpful to start with something grounding such as saying "Notice your back against the chair and your feet firmly planted on the ground.  Take a moment to anchor yourself here."

  4. Then it can be helpful to focus on the breath for a few moments before getting into a non-breath focused exercise. You might say something like “Bring your attention to your breath. Notice your inhales and exhales. Do not force your breath, but instead allow your breath to breathe you.”

  5. Explain the exercise (e.g. leaves on a stream). For instance, “You are sitting at the bank of a river under a leafy tree. Notice what it feels like to sit on the ground. Is it soft or hard? Now notice the river. Which direction is it flowing? How fast is the water moving? Bring your attention to the sun over head. How brightly is it shining? Continue to imagine yourself at the bank of this river. Whenever your mind gets distracted, put your thought on a leaf from the nearby tree and let it float down the river. Each time your mind wanders, simply reimagine yourself on the bank of a river, put your thought on a leaf, and watch it float away.”

  6. Every 10-30 seconds prompt a refocus. For example, "If your mind has wandered, that's ok because that's what minds do. Simply acknowledge that it has done so and willingly bring your attention back to the exercise (e.g. sitting on the bank of a river).

  7. Signal the end of the exercise by saying something like "Now, before we end, bring your attention back to your breath."

  8. Signal that attention should be brought back into the room "Start to notice yourself sitting in your chair."

  9. Prior to ending, tell everyone "Now I'm going to ring the bell twice, and after the second bell stops ringing, you can go ahead an open your eyes."

  10. Give everyone a moment to settle in.

  11. Ask for observations.

  12. Be sure to verbally and non-verbally (smile) reinforce efforts to refocus attention, willingness to participate, and improvements since starting mindfulness practice. For instance, in response to someone saying “my mind wandered, but I was able to refocus back on the exercise,” you might say “really nice job catching your thoughts and willingly refocusing on the exercise.”

And that’s all there is to it!

Conducting mindfulness exercises can be challenging, but with practice it can be rewarding.

I very much hope this was helpful! Please feel free to leave comments.



Announcement: Intensive Program for Adults with Eating Disorders Now Opened in the NY-Metro Area!

by Tara Deliberto, Ph.D.

I'm very excited to announce the opening of a new intensive program from adults with eating disorders at NewYork-Presbyterian Hospital!  This program runs from 8:30am-3:00pm, Monday-Friday, and provides adults with eating disorders the opportunity to eat three times per day with the support of caring and well-trained behavioral specialists.  In addition to meal and snack support, patients receive individualized care while having access to a host of groups focusing on goals such as establishing understanding and use of cognitive behavioral therapy skills, mindfulness practice, assertiveness, and the regulation of one’s emotions.   Taken together, the services offered to our patients - including meal and snack support, individual therapy, family therapy, and group sessions - foster both mental and physical recovery from disabling and life-threatening eating disorders.   


Although our eating disorders partial hospitalization program (ED PHP) is new, New York-Presbyterian Hospital has served the community by treating patients in both inpatient and outpatient settings for many years. Our specialized eating disorders inpatient unit helps people psychologically recover from eating disorders, while benefiting from close medical monitoring of physical symptoms resulting from food restriction & avoidance, purging, laxative use, and other eating disordered behaviors.  Additionally, we have outpatient services where people with eating disorders can see licensed mental healthy professionals for 1-2 sessions per week.  Until now, however, patients with any form of insurance in the NY-Metro Area have not been afforded the opportunity to have an intermediate level of care in a hospital setting in which support, psychological services, & medical monitoring are provided consistently throughout the week.


In this new eating disorders partial hospitalization program (ED PHP), patients are treated & supported by staff from the disciplines of nursing, social work, psychology, nutrition, & psychiatry, who work together to help people recover both mentally & physically from the effects of the eating disorder.  Leadership of this new program will include myself, Tara Deliberto, Ph.D., Assistant Professor of Clinical Psychology in Psychiatry at Weill Cornell Medicine, and Director of the Eating Disorders Center’s Partial Hospitalization Program at New York-Presbyterian Hospital, as well as Evelyn Attia, MD, Professor of Psychiatry at Columbia University Medical Center, Professor of Psychiatry at Weill Cornell Medical College, Director of the Eating Disorders Research Program at the New York State Psychiatric Institute, and Director of the Columbia Center for Eating Disorders at Columbia University Medical Center.   


For more general information about the Eating Disorders Center: http://www.nyp.org/psychiatry/services/center-for-eating-disorders.  More info on the ED PHP will be up soon!