The essentials of comprehensive eating disorder treatment presented by Katie Thompson & Erin McGinty. Katie and Erin presented on the goals and objectives when developing a comprehensive treatment plan.
Comprehensive Treatment of Eating Disorder- Katie Thompson & Erin McGinty
The Essentials of ComprehensiveEating Disorder TreatmentCastlewood Treatment CenterPreferred Provider ConferenceJanuary 25, 2013Erin McGinty, LPC, NCC, andKatie Thompson, LPC, NCC
No. 1: Assessment and History-Takingform the Foundation of Treatment
No. 1: Assessment and History-Taking asthe Foundation of TreatmentRules of Thumb:o Never assume that a question has been askedbeforeo Be specific and thorougho Neutral presenceo Be on the lookout for patterns andrelationshipso Your conceptualization and treatment plan areonly as strong as your assessment
Initial Eating Disorder Assessmento Chief Complainto History of Current Illnesso Medical Complicationso Treatment Historyo Family Historyo Co-Existing Conditions
Initial Eating Disorder Assessment:Chief Complainto Client identifies what he/she is seekingtreatment foro Assessment of motivation and willingnessto change symptoms
Initial Eating Disorder Assessment:History of Current Illnesso Changes in weight and shapeo Restrictiono Fastingo Skipping mealso Restriction of overall caloric intakeo Avoidance of foodso Good vs. bad foodso Religious or food restrictionso Food allergieso Diet pillso Identify affective, interpersonal, or other triggers
Initial Eating Disorder Assessment:History of Current Illnesso Binge Eatingo Objective versus subjective binge episodeso Many clients emphasize loss of control and violation ofdietary standards to define a binge, not the volume offood consumed (Anderson, Lundgren, Shapiro, &Paulosky, 2004)o Frequency of episodeso Identify affective, interpersonal, or other triggers ofbinge eating episodeso Volume of foodo Types of foodo Post-binge consequences
Initial Eating Disorder Assessment:History of Current Illnesso Purgingo Self-induced vomitingo Laxativeso Diureticso Ipecaco Enemaso Insulin abuse for diabeticso Chewing and spittingo Ruminationo Frequencyo Identify affective, interpersonal, or other triggers
Initial Eating Disorder Assessment:History of Current Illnesso Exerciseo Frequencyo Typeo Intensity/durationo Patterns/repetitiono Degree of compulsivenesso Relationship to food, violation of eatingdisorder rules, and weight
Initial Eating Disorder Assessment:History of Current Illnesso Highest and lowest weightso Experience of puberty and menstruationo Amenorrhea and relationship to food andweight patternso Ask the client what weight she considers tobe ideal for hero Ask the client how she sees herselfcurrently; underweight, of average weight,or overweight?
Initial Eating Disorder Assessment:Medical Complicationso Physical consequences of the eatingdisorder (e.g., osteoporosis, osteopenia)o Hospitalizations
Initial Eating Disorder Assessment:Treatment Historyo When?o Where?o For how long?o What was the outcome?o What therapies were helpful and unhelpful?o What were the experiences within thetherapeutic relationships?
Initial Eating Disorder Assessment:Other Important Informationo Co-existing conditions (e.g., anxiety,depression, mood disorders)o Physical assessment (History & Physical)o Family history of mental illnesso Family dynamics and relationshipso Developmental history (e.g., interpersonalrelationships, trauma, neglect, bullying)
Assignments Related to Assessment andHistory-Takingo The Timeline Assignmento Write out what a typical day in your eatingdisorder looks like.o Write about the worst day in your eatingdisorder.
Case Conceptualizationo Transdiagnostic approach (Fairburn)o Key behaviors, cognitions, and emotionso Forming a context in which to understandcurrent behaviors and patterns; importantfor both the therapist and cliento Predisposing, precipitating, andperpetuating factorso Core beliefso Origins
Case Conceptualization andSchema Therapy (Young, 2003)o Schemas (Young Schema Questionnaire (YSQ-L2) andYoung Parenting Inventory (YPI))o Links to the presenting problemso Schema triggerso Hypothesized temperamental factorso Developmental originso Core memorieso Core cognitive distortionso Coping behaviorso Modeso Effects of schemas on the therapeutic relationshipo Change strategies
Assignments Related toCase Conceptualizationo Write about the messages you received aboutemotions such as anger, sadness, guilt, shame,happiness, and fear growing up. How did youobserve these emotions being expressed in yourfamily of origin? What beliefs did you developabout emotions as a result?o Write out the overt and covert messages youreceived from your family around food, weight,and shape.
Restricting, Bingeing, and PurgingExtends Beyond Foodo A person who Restricts, Binges and Purgesfood also does so with most of what theyconsumeo Relationships, clothing, emotions, thoughts,information, possessions, needs,alcohol/drugs, etc.o Restricting, bingeing, & purging are learnedfrom interactions in relationships with primarycare givers & significant individuals.o When a person R, B or P it is a representationof what they have learned in relationships.
Bingeing On More than Foodo Bingeing represents taking in what a person hasrestricted, feels they do not deserve or what they will notgive themselves in balance.o Bingeing will often take place after periods ofdeprivation. “I cannot have this, but I need/want it.”o Objects consumed in bingeing are not enjoyed orconsumed in a mindful manner.o A client who binges upon food will often also bingeupon a person or a relationship. When they findsomeone “safe” they will try to get as much of the personas they can, fearful of when that person will no longer bepresent.
Restricting More than Foodo Restriction is a manifestation of self-hate &deprivation.o A client who restricts food will often restrict basicneeds: toiletries, sleep, relationships, enjoyment,undergarments, connection & even electricity .o Often this has been modeled, taught or learned inthe context of neglect, abuse, trauma or witnessinganother’s deprivation.o Individuals report feeling “undeserving,” &unworthy, that restriction allows them to relieve thedistress & anxiety felt when they have needs andwants. It can be punishment.
Purging More than Foodo Shame & self hate often result after a personconsumes what they have restricted or binged.o Purging allows a release of what they feel theycannot keep, have, or hold inside.o A person will purge objects they have purchased,anger, a person/relationship & information.o Often a person will report that they felt “out ofcontrol,” or “overwhelmed,” before they purged.o Discomfort, anxiety & anger are common emotionsassociated with the purging of food, emotions,information or personal items.
Assignments Related to the EatingDisorder as More than Foodo Write a list of everything that you restrict,binge, and purge. Where did you learn thesebehaviors, what was modeled/taught to you?o Write an extensive list of all of your needsand your wants. Write about how youlearned about needs and wants. How does itfeel to have needs and wants?o Write about what you would say instead, ifyou could not restrict, binge, or purge.
No. 4: The Eating Disorder is aProtector, not a Villain
The Eating Disorder is a Protector,not a VillainApproach No. 1 to Eating Disorder: “Edsmanipulative and controlling style has madehim an abuser, source of desperation, andvillain to people across the globe.” (JenniSchaefer)Pros and cons to using this approach?
The Eating Disorder is a Protector,not a VillainApproach No. 2 to Eating Disorder: Theeating disorder is protector, and has servedto keep a client safe and- in some instances-has been absolutely necessary for them tosurvive.
The Eating Disorder is a Protector,not a Villain“When the body is mistreated, neglected, or violated, oneexperiences a loss of control over it and need somehow toget control back. Eating disorders represent a tenuousfeeling of control, which has been achieved through thebody. Controlling the body, and what goes in and out of it,becomes an adaptive and defensive reaction to past neglect,abuse, and developmental deficiencies.Starving, binging, and purging may be used as adaptivefunctions for a disordered self. Disordered eating patternsare, in part, attempts to resist with the body and to define,establish, or restore a sense of self.” (Costin, 1996).
The Eating Disorder is a Protector,not a Villain“Compulsion is despair on an emotional level.Compulsion is the feeling that there is no one home.We become compulsive to put someone home.All we ever wanted was love. We didn’t want to becomecompulsive about anything. We did it to survive. Wedid it to keep from going crazy. Good for us” (Roth,2001).
The Eating Disorder is a Protector,not a Villaino Therefore… we show gratitude for the eatingdisorder and the ways in which it has servedour clientso Clients feel understood and this approachcreates less polarization in the therapeuticrelationship
Assignments Related to theEating Disorder as a Protectoro Have your eating disorder write a letter toyou, explaining all of the ways it hasprotected you over time.o Write a letter in return to your eatingdisorder, expressing gratitude for all of theways it has protected you.o Draw five scenes depicting times in whichyour eating disorder protected you.
No. 5: Every Eating Disorder BehaviorServes a Function, that Function isDifferent for Each Individual, and theFunction Changes Over Time
Every Eating Disorder Behavior Serves aUnique Function“Rather than experience the loss of control that loving brings,many of us choose to feel out of control about somethingthat is within our control; the food we eat—or don’t eat.I learned to be frightened of my binges in the same way that Iwas frightened of my mother…there was no telling when shewould hit me…there was no such thing as being safe.Which…is exactly how I felt around food...I transferred theterror that was outside of me—my childhood terror—to aterror that was inside of me. When we are compulsiveabout food, we recreate familiar feelings of being out ofcontrol…but his time the feelings are encompassed by atiny—and much safer—radius: the food that goes in ourmouths, the weight that goes on our bodies” (Roth, 2001).
Every Eating Disorder Behavior Serves aUnique Functiono The eating disorder has a “what” & a “why”o What the person gets out of ito Why the person continues to engage in theeating disordero The eating disorder says & demonstrates whata person often cannot directly exhibit orexplaino The functions are different and multipleo Functions evolve over time, and are basedupon past & current unmet needs
Every Eating Disorder Behavior Serves aUnique Functiono The function is a way of demonstratingwhat the person cannot create or obtainwith normal meanso The client may need control, sense of safety,familiarity or to recreate a way to makethemselves feel like a perpetrator madethem feel
Every Eating Disorder Behavior Serves aUnique Function“Early Maladaptive Schemas fight for survival…this is theresult of the human drive for consistency. The schema iswhat the individual knows. Although it causes suffering, itis comfortable and familiar. It feels ‘right.’ People feel drawnto events that trigger their schemas. This is one reasonschemas are so hard to change. Patients regard schemas asa priori truths, and thus these schemas influence theprocessing of later experiences. They play a major role inhow patients think, feel, act, and relate to others andparadoxically lead them to inadvertently recreate in theiradult lives the conditions in childhood that were mostharmful to them. Schemas begin in early childhood oradolescence as reality-based representations of the child’senvironment.” (Young 2003)
Functions of the Eating Disordero Survival Strategyo Provides Comforto Inability to express internaldistress to otherso Call for Helpo Fear of Responsibility & ofGrowing Upo Manifestation of unresolvedtrauma and deprivationo Having something that isone’s own and not controlledby otherso Numbingo Substitute forLove/Affection/Attachmento Rebelliono Coping Mechanismo Substitute forRelationship/Intimacyo An OCD ritualo Covers Horrific Memorieso Manifestation of a parent’sunfinished businesso A need to care for someoneand escape at the same timeo A way to be out of controlprivatelyo Relief for depression anddistresso Keeps others away
Assignments Related to the Function ofthe Eating Disordero Write out what you get out of the eatingdisorder and why it “works” for youo Identify the unmet needs related to the“what” and “why” of the eating disordero In your own words, write out what the eatingdisorder says/shows for you that isunspoken
No. 6: The Eating Disorder SignifiesUnfinished Business
The Eating Disorder SignifiesUnfinished Businesso The eating disorder is a way of playing out what is unresolvedfrom the pasto The eating disorder is a way of keeping a person from goingout in the world and leaving a problem unsolved and behindo The eating disorder keeps bringing a person back to andrecreating the painful episodes in which they needed a safeother to help them process and manage their realityo Example: “My binge/purge episodes are a recreation of thebeautiful dinners my mother used to serve on china that myfather turned into his militaristic battle grounds. I can stillsee my father slamming my brother’s face into his mashedpotatoes over and over.”
The Eating Disorder SignifiesUnfinished Businesso The starvation from the Holocaust (legacy burdens)o The incest from childhoodo The abuse that took place around food, with foodo The deprivation that allowed parents/oldergenerations to survive depressions and emigrations(legacy burdens)o The eating disorder started at the age mother wassexually abused; mother could no longer connectwith daughter once she reached the age of the abuseo The rules and chaos from a parent’s birth country
No. 7: The Eating Disorder Is thePrimary Relationship
The Eating Disorder as the PrimaryRelationship“Food was our love; eating was our way ofbeing loved. Food was available when ourparents weren’t. Food didn’t get up and walkaway when our fathers did. Food didn’t hurtus. Food didn’t say no. Food didn’t hit. Fooddidn’t get drunk. Food was always there.Food tasted good. Food was warm when wewere cold and cold when were hot. Foodbecame the closest thing we knew of love.”(Roth, 2001).
The Eating Disorder as the PrimaryRelationshipo The eating disorder often serves as a means of meeting unmetneeds stemming from primary childhood relationshipso Safety, soothing, comfort, security, predictabilityo The eating disorder can take on a parental presenceo The eating disorder serves as a “wedge” between the client andothers; the eating disorder is a less threatening, less volatile, lessvulnerable relationship to be in“The very purpose of compulsion is to protect ourselves from thepain associated with love” (Roth, 1991).o The eating disorder provides a sense of “companionship,”combating feelings of loneliness, inadequacy, and shame
Assignments Related to the EatingDisorder as the Primary Relationshipo Write about how your eating disorder isyour primary relationship.o Create a collage depicting the following: 1)What every child needs, 2) What youreceived, and 3) What needs your eatingdisorder meets.o Write about how your eating disorder servesas a “wedge” between you and others.
No. 8: The Eating Disorder MirrorsOther Relationships
The Eating Disorder as a Mirroro The eating disorder will often cycle in a manner that mirrors therelationship dynamics from the family of origino These dynamics are unique to the person, and can ebb and flowo The person will restrict affection (and food) to mirror thedeprivation in both parental relationships they experiencedo There will be periods of bingeing upon connection (and food)when it is available, to satiate the fear of not knowing when thenext time for connection will be availableo Purging will follow periods of connection when experiencingdiscomfort in being vulnerable, “needy” or emotionally present.This will often manifest in food as a representation
Assignments Related to the Eating DisorderMirroring Relationshipso Write about the metaphors for your eatingdisorder and how it is similar to therelationships you have with people; where elsein life do you restrict, binge, or purge?o Describe the relationship dynamics/patternsyou witnessed growing up in your family. Whatwere these like to experience? How do yourecreate these dynamics in food, exercise, withyour body and with others? Depict in words andillustrate.
No. 9: The Eating Disorder MirrorsAttachment Arousal Patterns
Parallel Arousal Systems: Attachment(Crittendon)Attachmento Paino Fearo Angero Desire for Comforto Comforto Boredo Tiredo Sleepo DepressionSexualo Sexual Paino Sexualized Terroro Aggression/Submissiono Romanticismo Affectiono Satisfactiono Afterglowo Sleepo Numbness
Parallel Arousal Systems: AttachmentAttachmento Paino Fearo Angero Desire for Comforto Comforto Boredo Tiredo Sleepo DepressionFoodo Starvation/Stuffingo Forbidden/Fear Foodso Anger at Foodo Fantasizing about Foodo Food as Comforto Satiationo Exhaustion after R/B/Po Hangover/Sleepingo Numbness
No. 10: It’s Not about the Food…but It Is about the Food
It’s Not about the Food…but It Is about the Foodo The relationship with the food has to berenegotiatedo Deconstructing the meaning of foodo Therapeutic mealso Mindful eatingo Exploration of rituals at the tableo Exposure and response prevention therapy
Assignments Related to Renegotiating theRelationship with the Foodo Write about all of your rituals at the table inexhaustive detail. What is the function ofeach? What are the fears around change?o Write about your fears of allowing yourselfto taste, enjoy, and desire food.
Buy 10… Get One Free!No. 11: Relapse Prevention is Key
Relapse Prevention is KeyEssential Principles:o Relapse prevention is about more thanavoiding relapse; it is about learning how tolive life without the eating disordero Every urge signals an unmet needo Adaptive Coping Responses (ACRs) shouldbe geared toward meeting the unmet needo The intensity of the intervention(s) need tomatch the intensity of the unmet need
Relapse Prevention is Keyo It is necessary to look at the beliefs that keep aclient from using her relapse prevention plan(e.g., I don’t have needs; I don’t deserve to meetmy needs; Meeting my needs is selfish)o Abstinence Violation Effect (AVE) is animportant teaching point, especially for certaintypes of clientso Containment, grounding, self-care, and self-soothing strategies need to be taught
Relapse Prevention is Keyo Identify high-risk situationso Identify warning signs of relapseo Differentiate between a lapse and a relapseo Maintaining a balanced lifestyleo Looking at unhealthy relationships andbuilding healthy support systemso Identifying deficiencies in life skills, and lifeskill training
Assignments Related toRelapse Prevention and Beyondo Urge cardso Behavioral Chain Analysis (BCA)o Write out your next relapse in exhaustive detail.o Write about the life skills you possess but feelinsecure about, the life skills you know you do nothave, and the fears around dealing with specificthings that create anxiety within.o Create a collage of what you wanted to purge whenyou purged last night. Include thoughts, feelings, etc.What other alternatives could you have used to“purge” these thoughts and feelings?
ResourcesAnderson, D. A., Lundgren, J. D., Shapiro, J. R., & Paulosky, C. A. (2004).Assessment of eating disorders: Review and recommendations for clinicaluse. Behavior Modification, 28(6), 763-782.Costin, C. (1996). Body image disturbance in eating disorders and sexualabuse. In M. F. Schwartz & L. Cohn (Eds.), Sexual abuse and eatingdisorders (113). New York, NY: Brunner/Mazel, Inc.Roth, G. (2001). When food is love. New York, NY: Penguin Group USA, Inc.Mitchell, J. E. & Peterson, C. B. (Eds.). (2005). Assessment of eating disorders.New York, NY: The Guilford Press.Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: Apractitioner’s guide. New York, NY: The Guilford Press.