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.


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:  More info on the ED PHP will be up soon!



In Comprehensive BITE Stage 1, BITE Family Therapy and BITE Group were thoughtfully created to compliment each other.  During Stage 1 BITE Family Therapy, the therapist teaches parents to take control of food responsibilities.  Parents also learn to coach the patient in eating meals/snacks and help them through difficult eating disorder urges.  Stage 1 BITE Family Therapy terminates when the patient has reached weight restoration and stabilization.  Although this is likely to improve the patient's cognitive and emotional functioning, the addition of Stage 1 BITE Group is intended to expedite this process.  Stage 1 BITE Group has been designed to specifically facilitate acceptance of parental control over food, provide skills training, and increase recovery behaviors (as defined in the BITE Handouts) early in treatment.

With improved physical and psychological health at the completion of BITE Stage 1, the timing is ripe for the introduction of CBT coping skills to support the patient’s process of reclaiming independence.  Stage 2 BITE Family Therapy is focused on gradually and systematically handing over food responsibilities - called Earned Freedoms in BITE - to the patient.  Especially for patients scared of the eating disorder returning, this process can be very anxiety provoking.  As such, Stage 2 BITE Group is administered alongside Stage 2 BITE Family Therapy to impart coping skills.  While Stage 1 BITE Group primarily focuses on traditionally "third wave" acceptance and mindfulness strategies, Stage 2 BITE Group focuses mostly on the development of CBT skills (e.g. thought disputation).  Skill building in Stage 2 BITE Group also lays the necessary groundwork for exposure exercises in Stage 3.     

After the patient’s weight is stable, eating disorder behaviors have significantly decreased, and coping skills are in place, a transition to BITE Stage 3 is made.  In this crucial final stage of BITE, the patient receives individual therapy twice per week.  One type of session fosters self-directed eating, while the other aims to improve body image.  In the former type of individual therapy, patients are guided to eat regularly (three meals and two snacks) and according to their own appetitive cues of hunger and fullness.  We call this Regular and Appetitive Eating or "RAE."  Alongside RAE, the patient receives Body Acceptance and Exposure or "BAE."  BAE includes a series of body size/shape/weight acceptance and exposure exercises (e.g. imaginal exposure of seeing a weight a few pounds higher on the scale) that facilitate anxiety reduction.  This type of body image work is saved until Stage 3 because the patient’s weight has been restored and stabilized at this point in treatment.  Lastly, throughout both RAE & BAE in Stage 3, self-sufficiency and relapse prevention are underscored.

Using Cool Temporary Tattoos in Therapy

by Tara Deliberto PhD

Decreasing eating disorder behavior is a main part of any treatment for anorexia nervosa, but in BITE, we also focus on increasing recovery behavior.  Recovery behavior can be anything from actively using coping skills to eating an entire meal without having an emotional outburst.  Providing reinforcement to adolescents with eating disorders is an important part of increasing recovery behavior in BITE.   But coming up with ideas for reinforcers can be tough!  Sure, non-verbal cues like smiling or providing verbal encouragement can be tremendously helpful, but what can the adolescent work for in treatment?  Just working towards "getting better" isn't going to cut it with this crowd.  Working towards obtaining something enticing can be a powerful motivational tool in eating disorder treatment.  The problem is that tangible rewards for teens can become expensive pretty quickly.  

So, what about the really cool temporary tattoos that Tattly makes?  Those seem like a good idea, and not just because they're affordable.  Any Tattly would make a good reward because so many adolescents love them.

Beyond just making a good reward, Tattlys can be used more artfully in treatment as well.  Because most eating disorders are accompanied with poor body image, simply placing any cool temporary tattoo on a body part judged to be "disgusting" by the patient can begin to create a new mental association with that area.  The idea is that while that body part used to be negatively judged, the addition of a Tattly would now add a positive judgement.  And perhaps more importantly, if an adolescent is prone to avoiding looking at that body part, having a cool temporary tattoo on the area might facilitate a decrease in the eating disorder symptom of body avoidance.  In addition to placing Tattlys directly on negatively judged body parts, the Tattly intervention can also be helpful more broadly to patients with eating disorders.  Below are examples of how Tattlys can be used in conjunction with BITE.  

Specific to Stage 1 BITE:

Specific to Stage 2 BITE:

Specific to Stage 3 BITE


We some of the ideas in this post inspired you!  Keep us posted on how your intervention with Tattlys went over.  Please feel free to leave comments for us on this post.