CBT Guided Self Help –Part 3/3 Dr Beth Shelton Senior Clinician Victorian Centre for Excellence in Eating Disorders Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
CBT Guided Self Help –Part 3/3 Dr Beth Shelton Senior Clinician Victorian Centre for Excellence in Eating Disorders
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
CB GSH:
6 step cumulative model:
Step 2: Instituting a meal plan
)
Step 1: Monitoring Your Eating
Step 3: Intervening in Binge Eating
Step 4: Problem Solving
Step 5: Eliminating Dieting
Step 6: Changing Your Mind
Each step involves adding something to what has already been done in the preceding step(s Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Step Two: Instituting a meal plan
• Learning to eat three meals and two or three snacks a day • Setting up in advance exactly when you should (and shouldn’t) eat
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Importance of planning Creates a secure, regular pattern of eating
makes an explicit requirement not to eat at other
times
Develops capacity to organise own eating
Sample Meal Plan/times
– 7:00 am Breakfast
– 10:00 am Snack
– 12:30 pm Lunch
– 3:30 pm Snack
– 6:30 pm Dinner
– 8:30 pm Snack Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Step Two: Meal Planning
When to eat should be determined by
plan not by hunger or urges to eat
Initial focus on when you eat not what you
eat
“rule of 3”
– 3 meals, 2-3 snacks
– 3-4 hrs. apart Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Reflecting on the meal plan
Review what is happening to client’s
eating – firstly regular eating
When regular eating is established -
does eating need to be more substantial
to ward off binges triggered by hunger?
Encourage client to review “normal”
portion size
e.g: use someone else as a reference
point; consider (non-diet) prepared
meals for one Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
• Step Two: Grace
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Before moving on to step three • Not necessarily a week of “good days”
• Is she planning regular meals and snacks?
• Is she trying to restrict her eating to only the planned meals and snacks?
• Is she getting back on track when things go wrong?
• Is she adjusting to accommodate special circumstances?
• Is she reducing/ eliminating vomiting and diuretic/ laxative misuse?
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
CB GSH:
6 step cumulative model:
Step 2: Instituting a meal plan
)
Step 1: Monitoring Your Eating
Step 3: Intervening in Binge Eating
Step 4: Problem Solving
Step 5: Eliminating Dieting
Step 6: Changing Your Mind
Each step involves adding something to what has already been done in the preceding step(s Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Step 3
Learning to Intervene to Prevent Binge Eating
Developing and trialling strategies to manage the urge to binge
Develop further skills and resources to reduce binge eating episodes in addition to those already begun
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
What is a binge? • Not just over-eating
• 2 criteria – Excessively large quantity of food
– Subjective loss of control
• Specific quality
• Accompanying emotions & thoughts – Shame, remorse, self-disgust
• Impulsive • Compulsive • Pre-planned • Chaotic
• Methodical
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Step Three: Learning to intervene to prevent binge-eating
1. Psychoeducation (direct to Cooper manual)
• What is a binge
• What maintains the binge eating cycle
• Binge eating triggers
2. Introduce skills
• Planning ahead
• Intervening in the moment
• Begin to list alternate activities
• Trial and adapt as homework
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Practice Skills: Intervening in the moment
• Time must pass – urge awareness, surfing, distraction
• Client must make it more difficult to binge
• Generate a list of things to do instead of (unplanned) eating
• Plan pleasurable activities
• Helpful for client to create a provisional list, experiment with how it works and update the list
• Can modify stimulus as well as reponse
Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Step Three: Learning to intervene to prevent binge-eating
• Planning ahead, identifying potential problems and recognizing the urge to binge early in the process and taking evasive action can prevent binge-eating
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
• Step 3 Grace
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Step THREE Key Messages:
• Binge eating is NOT inevitable once eating goes wrong
- it is possible to stop a binge once started
• Each successful ‘intervention’ makes future interventions easier
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
CB GSH:
6 step cumulative model:
Step 2: Instituting a meal plan
)
Step 1: Monitoring Your Eating
Step 3: Intervening in Binge Eating
Step 4: Problem Solving
Step 5: Eliminating Dieting
Step 6: Changing Your Mind
Each step involves adding something to what has already been done in the preceding step(s Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Step 4
Problem Solving
Learning problem solving steps and applying them to both eating and other problems
Reduce binge eating as unhelpful coping behaviour
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Step FOUR: Problem Solving
1. Psychoeducation (direct to Cooper manual)
• Problem solving & the brain
• Binge eating
• Common problems
2. Introduce skills
• 6 step problem solving model
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Proactive Problem Solving
1. Identify the problem as early as possible
2. Specify the problem accurately
3. Consider as many solutions as possible
4. Think through the implications of each solution
5. Choose the best solution or combination of solutions
6. Act on the solution
7. Critically reflect on the entire process
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Typical problem themes
• Problems with eating • Depression
– Assess global vs. specific • Relationships
– Relationship problems may become evident through monitoring, raise awareness
• Feeding Others – E.g.: Preparation, children, and leftovers
• Feeling Fat – May be automatic misinterpreted negative feeling,
physical vs. emotional triggers
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Practice Skills: Sample Problem
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Before Moving on to Step Five
• Has client been identifying problems which make her upset (sad, anxious) or like binge-eating and recording them?
• Has client been using problem solving techniques to deal with these?
• Has client found that recording and structured problem solving has helped them deal with circumstances which would have led to a binge?
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
CB GSH:
6 step cumulative model:
Step 2: Instituting a meal plan
)
Step 1: Monitoring Your Eating
Step 3: Intervening in Binge Eating
Step 4: Problem Solving
Step 5: Eliminating Dieting
Step 6: Changing Your Mind
Each step involves adding something to what has already been done in the preceding step(s Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Step Five: Eliminating Dieting
• Learning to stop dieting - restricting food intake
• Gradually re-introducing forbidden foods
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Eliminating Dieting
3 Ways of Dieting 1. Trying not to eat/fasting - should have been
addressed by ‘regular eating’/meal planning
2. Restricting (e.g. certain food groups. less than 1200 cal/day etc) - this needs to be addressed, not sustainable
3. Trying to avoid certain types of food (for fear of
effect on body weight/shape)- this needs to be addressed because it leaves vulnerable to future binges
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Eliminating restriction
How much food is “normal”???
• Modelling with a non-dieting friend/family
• Follow suggested serving sizes on packets
• No food is in itself fattening, and conversely eating too much of any food can be fattening
• Address dietary rules/rituals
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Eliminating avoidance of feared foods
1. Create hierarchy of feared foods list
2. Organize the list into degree of eating difficulty
3. Start by introducing foods from the easiest group and focus on them for a couple of weeks/days.
4. Then move on to the harder group and so on
5. Usually amount eaten is arbitrary, it tends to be the idea of having eaten it that is triggering
6. Stop when these foods are no longer unsettling
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
*Jenny’s List
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Practice skills: Food Challenge
• Basic exposure therapy ie behaviour with response prevention
1. Pick a food
2. Plan to eat it
3. Eat it in planned way
4. Review afterwards
5. Plan to eat another feared food
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Practice Skills: Coping with other types of avoidance
• Establish progressive goals
• E.g. eating with others
– Eat at home with friend/ relative
– Eat in restaurant with this person
– Eat in restaurant with people prone to make her anxious
– Eat in environment with people who are prone to make you anxious (e.g. parents)
Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Before moving on to step six
• Is client tackling the 3 forms of dieting?
• Are they eating enough food in meals/ snacks?
• Are they incorporating “dangerous” foods into their normal eating?
• Are they challenging other forms of avoidance?
• Are they able to eat in a controlled way, and in reasonable quantities, any food that they like?
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
CB GSH:
6 step cumulative model:
Step 2: Instituting a meal plan
)
Step 1: Monitoring Your Eating
Step 3: Intervening in Binge Eating
Step 4: Problem Solving
Step 5: Eliminating Dieting
Step 6: Changing Your Mind
Each step involves adding something to what has already been done in the preceding step(s Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Step Six Changing Your Mind
• Changing your mind about how important weight and shape are to you
• Growing a seed of doubt in the thin ideal
• Managing obsessive cognitions
Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Eating Disorder Mindset • A characteristic set of attitudes
and values concerning body shape and weight
• Thinness is idealised • Strenuous attempts to avoid
weight gain • Tendency to judge self worth
largely or even exclusively in terms of shape and weight
• Most other features can be understood as being secondary to concerns about weight & shape
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
Step Six: Changing Your Mind • Questioning the values supporting
overinvestment in weight and shape
• Thinking about the way you think
– Perfectionist - changing unrealistic goals and expectations and harsh self-evaluation
– All-or-nothing thinking
– consideration of alternative ideas
• Social media use….
• Self Compassion
• Alternative ways of thinking Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
The Counter Cultural Therapist?
• How do we negotiate the process of getting our clients to behave counter-culturally? – (i.e. eat normally when plagued with media pressure
to diet and/or overeat)?
• Explaining dieting as a risk factor • Dieting as a problem rather than • a solution • Cognitive dissonance strategies • Body image strategies • Self Awareness
Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney
CB GSH:
6 step cumulative model:
Step 2: Instituting a meal plan
)
Step 1: Monitoring Your Eating
Step 3: Intervening in Binge Eating
Step 4: Problem Solving
Step 5: Eliminating Dieting
Step 6: Changing Your Mind
Each step involves adding something to what has already been done in the preceding step(s Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney
Ending well
• Maintaining change
• Preventing relapse
• Make relapse plan
• Responding to lapses & slip-ups
• Concluding sessions
• Moving on
• Following up…
Beth Shelton - 2018 NEDC Members'
Meeting 1-2 June Sydney