Questions answered by BALANCE eating disorder treatment center™ and Lily Thrope, LCSW. Published February 16, 2026.
On February 13, 2026 we hosted a webinar for clinicians, "Becoming an eating disorder-informed therapist" with Lily Thrope, LCSW and founder of Thrope Therapy LCSW PLLC, and Melainie Rogers, MS, RDN, CDN, CEDS-C, founder and Chief Executive Officer of BALANCE Eating Disorder Treatment Center.
Clinicians had the opportunity to submit questions to our speakers, Lily and Melainie, before the webinar. Thank you to those who submitted questions — they have been answered below!
1. Co-occuring conditions such as ADHD when client reports they forget to eat, but has a history of ED, How do you differentiate?
For this case I highly recommend bringing on a dietitian that specializes in ADHD. Sometimes it is really tricky to spot the differences between ADHD symptoms (or any other mental illness) that leads to under eating vs avoidance with eating. They can often be really linked together and likely there is more connection here. Working in conjunction with a dietitian that specializes in ADHD can help you figure out which is which. I highly recommend https://www.brittanymodellrd.com/
2. I have been in active practice for more than 28 years, our understanding has developed so much over the years. I am also the parent of a teen with ARFID and it can be so hard to see the signs until someone helps pull everything together. Taking this seriously to pull together a team to support, including family is important. My child has family, nutritionist, psychiatrist, therapist, and PCP that work cooperatively with them to support her. Thank you for this talk and info!
Thank you so much for sharing your experience. There has been so much change in the ED field and I am always really inspired and excited about it. We have learned so much about how different clients are suffering and have developed stronger treatment tools to really meet the real life needs of clients and go beyond what the DSM and text books say. Echoing Melainie’s shout out to Sick Enough by Dr. Gaudiani. We didn’t get to talk much about ARFID in this training, but we have definitely learned more about this diagnosis and many treatment centers, including Balance have done a great job to meet the unique needs of these clients in addition to their other clients. The team approach is my favorite approach and I see it as the most effective approach. So glad you have an awesome team on your side!
3. How do we help a client in a larger body advocate for higher level ED care, especially if they are showing symptoms more aligned with anorexia rather than binge eating?
Thank you for this question. As I said in the webinar this question is all too familiar, but also makes me incredibly sad. People in larger bodies face a lot of treatment stigma and can receive delayed treatment due to this. Working with your client to have the language to express their symptoms and build confidence around advocating would be a great first step. As the clinician I would also try to get in touch with the clients other providers and help set the stage for what the client is needing and struggling with. Unfortunately living in a larger body can be a really hard part of ED treatment and I think some centers are doing better than others with this population. I also like to ask my clients if they prefer me to find referrals to clinicians in larger bodies which can go a long way in helping them feel safe and seen. One of my favorite dietitians to refer to is Chelsea Levy. We co-host Recovery Supper Club which is a safe place for people in larger bodies to gather.
4. When doing initial screening, what are some cues that a person might have an unhealthy relationship to food or their bodies that might tip us off, even if the person is being generally evasive or vague? (For instance, I work in substance use, and when a client starts listing a lot of substance use during initial history-gathering, there’s usually much more, even, that they aren’t yet disclosing— a clue that ppl who don’t work in this area might not catch.)
Great question. I think using the screening tool SCOFF could be really helpful as a first step. I think there is a balance between being direct and indirect to try to gather general information about a clients relationship with food and their body. It might take a few different sessions to present the idea of talking about food and body and eventually clients will usually share more about it. It can also be really impactful to ask about how their family conceptualized food or valued body size. You can learn a lot about what a client values based on how they talk about their parents values. Over time as you have more and more of these conversations you will pick up on the nuances and be able to notice things that are more subtle. Another great reason to bring on an ED specialized dietitian, IOP or therapist is to help with this assessment phase.
5. Melainie, you mentioned the gold standards for communications: is that the expectation for a good specialist center, no matter, if outpatient, IOP or residential?
The gold standard is for treatment centers to communicate with outpatient providers. Unfortunately sometimes this doesn’t happen and it can really impact the treatment success for a client. When I refer a client I make sure to have the ROI already signed before making the referral. This allows me to advocate for the client with the treatment center and try to get in touch with the intake coordinator to share additional context. Clients can mis-report on intakes so this collaboration of care is really important to avoid splitting and avoid delaying treatment. If you are not hearing from a treatment center after referral is made I highly recommend you reach out consistently to the center and speak to someone to share this experience.
6. How do you approach "subclinical" types of eating disordered behaviors, they have patterns that speak to restrictive eating but may not rise to the level of the meeting the diagnostic criteria to help them begin to recognize that there is a problem and find them the right support?
I treat disordered eating very similarly to eating disorders. It is really hard as the therapist to actually determine what is clinical or not with an ED. For one person a certain level of restriction will impact them similarly to a significant amount of restriction for another person. The diagnosis is not solely based on restrictive behaviors with food. It is also about how disruptive the body image distress is and how the body is coping with the changes to intake. I always encourage as a first step a physical, with an ED specialized doctor if possible, or their PCP. I encourage them to share that there is disordered eating going on and that they want to receive full assessment. Based on that initial assessment of lab work and the symptoms they are experiencing I figure out the next step, perhaps referral to dietitian, perhaps referral to treatment center, perhaps referral to a meal support group or increasing therapy sessions. There are many ways to increase support before referring to a higher level of care and these are some of the things I would consider before that for a disordered eating case.
7. What are some good resources to find out more information on ADHD, time blindness, and eating disorders?
I have seen some trainings on this. I would keep an eye out for trainings from ED treatment centers. You can usually sign up on their websites to receive emails about free CE trainings. I also found this blog post on the National Alliance for ED which is a great organization.
8. How do you know if someone has been in recovery long enough or strong enough to be a follow up care provider working on other goals (trauma, attachment, etc) using Art Therapy (I am an actual Art Therapist) and EMDR etc.
Awesome! I love Art Therapy and think it can be so helpful with continued ED care. For this question I would hope to be able to speak with previous providers of the client or understand from the client where they are in their treatment journey. Even if someone is in recovery for a long time, continued relapse prevention is necessary. This can look different for each person but I advocate for yearly physicals, updated screenings like SCOFF. If they are open to working with a dietitian that could be great to do on a monthly basis. As you work on things like trauma ED’s can be re-activated so it’s important to continue to assess for behaviors and symptoms ongoing.
9. Besides asking more detailed questions in our clinical interview about the person's relationship with food, exercise, and body image, what are some screening tools that we could use to help identify potential areas of concern?
SCOFF is the screening tool we recommend. We did not have time to cover this properly in the webinar but you can find it here. There are lots of other screening tools out there. See if there is one that resonates with you. I also like to add in some journal prompts and other things I have collected over the years. The Intuitive Eating Workbook can also be really helpful in determining someone's current eating habits and beliefs about food.
10. I've always come at ED behaviors from a perspective of relationship with food being a coping strategy. Coping with food, coping by restricting food... and dove into what is it that we are coping with... less about the eating behavior and more focus on what's driving that behavior... thoughts?
This is a really great insight. Often ED’s are so much more than they seem. There can be many complex emotional factors that play a role in ED behaviors. ED’s can develop as a coping strategy for clients and this also complicates letting them go. I also think of recovery as a grief oriented process since clients will have to grieve their ED as they start to recover which can be incredibly painful. Sometimes ED behaviors keep emotions in check and when clients start to recover all the emotions they were holding in start pouring out. This can also make recovery feel unsafe and scary. I like the way your thinking and it can be really interesting to explore this with clients. At the same time that you are exploring what is driving the behavior, the root does not always lead to relief. As Melainie shared, many clients need behavior change more immediately than the underlying therapeutic work. Keep that balance in mind!
11. Do we have an internet-based directory of ED trained PCPs or family doctors?
There are directories for this based on where you are located. Please send me a direct email (Email Lily Thrope here) with where you are located and I will try to get you the right resource.
12. Are there specific resources or "one pagers" of sorts with information on what is happening in the body for someone who has an eating disorder?
There are tons of these online. I don’t have a favorite one to recommend but if you find one and you want to share it with me I am happy to take a look. There are tons of resources on the Balance website too.
13. I am interested to know the benchmarks for terminating therapy.
I am interpreting this question to mean that you are interested in knowing when it is time to terminate with a client because they are needing a higher level of care treatment. This is a complex decision and there are a lot of different philosophies on it. Here is mine, I usually try to work with the client over a predetermined amount of time that we have agreed on like 2-3 weeks to see if any improvements can happen at outpatient, meaning with a dietitian on the team and doctor. If after the 2-3 weeks there are no changes then I let the client know that I am unable to see them at this level of care due to the clinical concerns for their medical safety and I make the referral to HLOC. Ideally I would be able to see this referral through and know that the client did reach out. Sometimes this does not happen. In the 2-3 weeks you can also come up with a clinical contract with the client, this is really a last resort for me because clinical contracts rarely are effective, but for some can be really helpful to see it all written out.
There is something called a harm reduction approach to eating disorders which might look like a highly skilled and trained outpatient team working with a client even though there are medical conditions present. This decision is complex and must be made with the care of a ED specialized doctor and clear guidelines on the frequency of visits for all providers on the team.
Hopefully this answers your question. I know this is a tricky one to give a clear answer to since all cases are very case by case. I highly recommend consulting with an ED supervisor or working with a treatment center to determine the level of care recommendation.