A Q&A with Dr. Tom Scales

Chris Clancy

October 31, 2018

Since founding White Stone Recovery Center in 2004, Dr. Tom Scales has been one of the guiding lights in the treatment of eating disorders in Nashville. Board-certified in internal medicine, psychiatry, and neurology, Scales has acted on a personal philosophy of providing a nurturing environment to clients so that they might better address the underlying wounds driving their self-harming behaviors.

“Individuals with an eating disorder don’t just have an eating disorder,” Scales said. “Oftentimes, they have another anxiety disorder or depressive disorder. And of course, they have a lot of the medical problems that come with purging or being underweight.”

JourneyPure acquired White Stone Recovery Center in 2017, and Dr. Scales now serves as an executive consultant while treating eating disorder patients at both JourneyPure Nashville intensive outpatient (IOP) centers. We sat down with Dr. Scales at his JourneyPure Nashville-Park Avenue office to chat about the treatment of eating disorders, mental health, and the spiritual dimension of recovery.

You’ve had a big standing in the community for years, at least since 2011. What led you to first open your own outpatient eating disorder treatment center, as opposed to signing on as the on-call therapist at a residential treatment center or hospital?

Honestly, I could have gone into a residential treatment program, but when it comes to ED [eating disorders], there wasn’t really one in this area. I didn’t want to leave Nashville, my family didn’t want to leave, so the next step was to try and grow and advance ED treatment in Nashville. For a while, I had a clinic located on the campus of Saint Thomas Hospital, in mid-town. I would admit people with ED and start tube feedings and stabilize them before sending them off to residential treatment somewhere else, which is kind of like doing detox before getting someone into residential addiction treatment. There were not a lot of physicians in town doing that.

My goal has always been to try and grow a program here in town that has a residential treatment component. That kind of led to my reaching out to [JourneyPure CEO] Kevin Lee last year and talking about that possibility.

Talk about the relationship between substance abuse and eating disorders. Are there any particular drugs that seem more conducive to one kind of eating disorder or another?

Bulimia seems to have more substance use associated with it, particularly alcohol. It seems like that’s a common co-occurring condition. People with anorexia tend to abuse more stimulants: cocaine, Adderall, even methamphetamine. And smoking.

A lot of the comorbidities associated with anorexia are OCD [obsessive compulsive disorder] and PTSD [post-traumatic stress disorder]. Of course, PTSD is high with all types of ED. A lot of times, these co-occurring conditions result in what I call the “whack-a-mole effect” for therapists. It seems that when the substance use gets better, the ED will get worse, and then you treat the ED and the substance use slips back in.

Why is that?

I think our brains are wired to deal with stress in whatever way they can. A lot of times people don’t just suffer from alcoholism and ED. They are also living with PTSD or depression, social anxiety, what have you, and so the alcoholism and ED are just these maladaptive ways to deal with the stress. You have to kind of treat all of that.

And though I’ve never been diagnosed with an eating disorder, I understand the cultural mindset. Women, especially, deal with pressure to be thin. They’ve been told by their cultures, their mothers, that they’re never going to get married unless they watch what they eat, and if they’re not thin, they’re worthless. It’s that kind of all-or-nothing thinking that leads to ED.

Have you seen opioid addiction contributing or complicating ED issues at all?

I don’t have the research in front of me, but I feel that, clinically, people with opioid addiction are more likely to have binge eating disorder than bulimia or anorexia. Binge eating is a disorder that affects the reward circuitry of the brain. If, say, eating a fudge sundae spikes the dopamine levels in your brain, taking the normal dopamine level from 100 up to 150 or so, something like heroin or methamphetamine will take it up to 1000. So I think binge eating disorder probably has more of a relationship with reward circuitry, as does opioid dependency.

With the study of eating disorders being a relatively new area of medicine, do you find it challenging to keep up with new breakthroughs, new discoveries?

Sure. I have to go to a lot of conferences. There are some good organizations. The Academy for Eating Disorders, that’s kind of like ASAM [American Society of Addiction Medicine] for ED. And there are always medical journals.

Can you talk at all about the spirituality side of ED treatment, keeping that top of mind when you’re treating patients who have a strong spiritual side?

I think ED is kind of a bio-psycho-social-spiritual-cultural-social disease. It really is all those things. And one’s spirituality has an important impact on recovery. Sometimes, unfortunately, one’s spirituality can also sustain an eating disorder.

The worst kind of quote-unquote spiritual abuse that I’ve ever seen involved a patient with bulimia who was a member of a church, and this church told her, “You can’t have a leadership position here, because your sin is so apparent.” She was overweight. She had bulimia. And they were basically telling her she wasn’t welcome because she had the sin of gluttony.

I think a person, when they go through ED treatment, a lot of times they’re going through much the same process as with substance abuse treatment. In each case, they need to realize, “Hey, I’m powerless over this thing, it’s taken over my life and it’s not working for me anymore. I need help.”

That is the spiritual aspect of recovery, the message of freedom and grace that spirituality offers. People can get murdered, spiritually, in certain church settings, and so it takes time to see how spirituality is really about grace and forgiveness. From that perspective, God doesn’t want us to be the thinnest or the best at whatever. Everybody has different abilities and capabilities, and everyone has an important role to be who they are with the talents they’re given, which is equally as beautiful.