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Creating an Innovative and Effective Treatment Plan for Binge Eating Disorder; Moving Beyond Traditional Approaches with IFS, Experiential, and Exposure & Response Prevention Therapies Castlewood Treatment Center Webinar February 20, 2013 Katie Thompson, MS, LPC, NCC Castlewood Treatment Center for Eating Disorders www.castlewoodtc.com [email protected]
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Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Aug 31, 2014

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Katie Thompson presents on the comprehensive treatment of Binge Eating Disorder. This presentation explores combining the theories of DBT, ERP, IFS and Experiential approaches.
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Page 1: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Creating an Innovative and Effective Treatment Plan for Binge Eating Disorder; Moving Beyond Traditional Approaches with IFS, Experiential,

and Exposure & Response Prevention Therapies

Castlewood Treatment Center WebinarFebruary 20, 2013

Katie Thompson, MS, LPC, NCCCastlewood Treatment Center for Eating Disorders

[email protected]

Page 2: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

FOOD AS PROTECTION?

“As long as my attention was consumed by what I ate, what size clothes I wore, how much cellulite I had on the backs of my legs, and what my life would be like when I finally lost the weight, I could not be deeply hurt by another person. My obsession with weight was more dramatic and certainly more immediate than anything that happened between me and a friend or lover. When I did feel rejected by someone, I reasoned that she or he was rejecting my body, not me, and that when I got thin, things would be different…the wonderful thing about food is that it doesn’t leave, talk back, or have a mind of its own. The difficult thing about people is that they do.”

~Geneen Roth

Page 3: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

LET’S BREAK IT DOWN

• The reality of Binge Eating Disorder• Identify components of the treatment process and

conceptualizing a BED case. • The Binge in detail: functions, triggers, interventions,

Anatomy of a Binge and Types• Identify traditional & necessary treatment• Identify innovative & crucial treatment• Miscellaneous concepts & approaches• Questions, questions, questions, discussion!

Page 4: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

THE SIZE AND COST OF BINGES:

•Typical: Between 1,000-2,000 calories consumed.

•25% of Binges included consumption of > 2,000 calories

•Subjective Binges: average or small amounts of food consumed in a binge; identified as a binge due to the sense of the loss of control.

•Objective Binges: truly large amounts of food consumed. Some binges can be 15,000-20,000 calories

Page 5: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

THE SIZE AND COST OF BINGES:•In 2009 a study reported the average, cost for binge food was around $30.5 a week, which adds up to almost $1,600 a year.

• Some participants reported spending as much as $3,500 on binge food a year.

•Totals including compensatory items used in the ED ranged from roughly $360 to almost $8,000 annually.

•By all accounts, this is grossly under-reported. Some clients report accruing $25,000 of debt in 1-3 years on binge food and other binge purchases.

Page 6: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Necessary Components for Treatment

• Gather a Thorough History and Assess Clienta. Physical, Risk, Dx, Comorbity, ED bxb. Hx of ED, family hx, Cognitions/Beliefs, TIBsc. Psychosexual, trauma hx, treatment hxd. Motivation, attachment, support system

• Establish Safety, Collaboration and Rapport• Integrate History/Data with Theory to Conceptualize Case

a. Transdiagnostic Approachb. Collaboration and Supervision

Page 7: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Necessary Components for Treatment

• Provide Psycho-Ed and Anticipatory Guidance• Symptom Containment and Introduce Relapse

Prevention• Functions of the Eating Disorder & other Bx• Correlating how Food/Body became objects• Identifying unmet needs & addressing• IDing relationship between Cognitions,

Emotions, Behaviors and Sensations

Page 8: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Necessary Components for Treatment

• IDing & addressing unresolved trauma, beliefs, unfinished business

• Seeing the ED as a protector, healing Exiled parts protected by ED & healing Protectors.

• Identifying & working with Legacy Burdens• Work with support systems • Behavioral Intervention for rituals/behaviors• Body Image/Affect/Cognitions/Sensations

Page 9: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Necessary Components for Treatment

• Revising Relapse Prevention; building interventions and adaptive coping mechanisms

• Addressing Sexuality & gender issues• Developing Earned Secure Attachment• Creating Balanced Living with life skills &

autonomy• Integrating recovery into life & adjusting• Building relationships with others

Page 10: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

FUNCTION OF THE BINGE:

• Survival Strategy• Provides comfort• Inability to express internal distress

to others. • Call for Help• Fear of responsibility and growing up• Manifestation of unresolved trauma

and deprivation• Having something that is one’s own,

not controlled by others.• Numbing• Substitute for

love/attachment/affection

• Rebellion• Coping mechanism• Substitute for relationship/intimacy• An OCD ritual• Covers horrific memories• Manifestation of a parent’s

unfinished business• A need to care for someone and

escape at the same time• A way to be out of control privately• Relief for depression & distress• Keeps others away

Page 11: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: Substitute for Love

“In that moment of spectacle my Will will stand paralyzed. In an instant I’ll be drawn into the reality of how empty my heart is, drawn instantly into a desperate part who believes no person is willing to fill my heart, the heart that swallows everything as I had just swallowed the meat. The meat eating is a metaphor for how vicious I feel inside. I’m desperate. I need nourishment. My binge part has ripped through mountains of food, searching for nourishment, searching for satiation, frantic for love.”

Page 12: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: Unfinished Business/Coping Mechanism

“The messages such as ‘you are bad’ respected no boundaries. They enveloped me and I felt abused and exhausted by them. So, I developed a mechanism to protect myself. I asked myself to believe that my self-loathing could live in food instead of inside of me; eventually the food became my self-hate. By creating this scenario, I could evade my inherent lacking by avoiding a vessel that carried hurtful messages. Ironically, I had decided to evade something essential to my survival so my plan backfired when I started to crave nutrition. I began craving food and eventually started bingeing, which fueled my hatred for the food; bingeing highlighted how unsafe food is. Bingeing meant that eating will surely possess me with self-hate; eating is something to be feared and avoided.”

Page 13: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: Manifestations of Unresolved Deprivation

“The physical deprivation/psychological deprivation binge happens for me under various circumstances. I can be especially drawn to a binge if I have successfully eaten according to my eating disorder’s strict orthorexic rules for a number of days. Forbidden foods become more alluring and I feel ashamed that I want them. My eating disorder is sure that my body doesn’t need them. There have been few times in the past few years that I’ve attempted to eat a small amount of a forbidden food. I tell myself that one to three bites are okay because they illustrate to other people that I don’t have a problem with food, that I don’t have an eating disorder…

Page 14: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: Relieve Stress “Typically, before I know it I’m eating much more

forbidden food than I had intended, I berate myself for doing so and I realize that I’m going to have to get it out. This happens commonly at restaurants. Sometimes I’ll eat more than one piece of bread from the bread basket or I will eat more than 1-3 bites of a dessert, which means that I’ve broken my rule. Those extra bites usually happen not because I am physically deprived but because I am frustrated by having to follow such rigid rules, tension builds and I snap.”

Page 15: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: To Keep Others Away“When stress is added to [the] pot, bingeing was occurring

because on top of my physical deprivation and strict rule following, I had no emotional regulator. Schoolwork and studying were enormous triggers for me. Anticipating social interaction was a trigger as well. I worried about being awkward and the bingeing and purging process would sooth the emotions I could not regulate and would eliminate my incessant ‘what-if-ing’ about the future social situation. The bingeing and purging could also give me an excuse to skip the social situation all together. ‘I feel sick. I feel tired. Look at how disgusting my face is now that I’ve binged and purged? My stomach feels upset and my body feels bloated.’”

Page 16: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: To Escape Responsibility Real or Imagined

“I internalize interpersonal conflict that isn’t actually happening because when I was young and wondered if it was happening, I didn’t have a viable adult to ask because my role in the family required that I take self-responsibility and also feel responsible for other people’s emotions. I wonder what I have done wrong when another person is not happy. So, unhappy people can trigger me to binge if I am not successfully able to gain reassurance that I did not cause the trouble.”

Page 17: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: To Numb“My perfectionism and self-criticism are always high, so I was

constantly finding fault within myself; this necessitated the bingeing. I couldn’t handle how hard I was on myself…What the fuck was wrong with me I would think? I couldn’t handle the thoughts, and remember, my body was already physically deprived. I didn’t have a chance. Bingeing worked to sooth these feelings and eliminate the cycling thoughts. My self-hate and my anxiety work to ensure that all rules be followed, otherwise they say that I am a worthless piece of shit. So, when I break the rules that are impossible not to break, I don’t want to sit around feeling like a worthless piece of shit, and then I would feel shame for not accepting my reality as a worthless piece of shit with grace, so my retribution was to restrict or I would eliminate all thoughts by bingeing and purging. The bingeing and purging silenced everything.”

Page 18: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge:

“Relief, Numbing, Escape, Satisfaction, Nurturing and Indulging…all in secret so no one has to know that I have needs or that I have any issues at all. I am fine. I am happy. I am need-free. Please love me. I promise I won’t be a burden. I’ll do my very best. Please love me.”

Page 19: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Illustration of The Binge & Purge

Page 20: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Illustration of The Binge & Purge“It commences in the morning with a simple thought

that just comes forward in my mind. ‘What do I want to binge on today?’ Bam, it is settled. The entire day’s agenda is cemented around the binge and purge…I want the night to be intimate with my eating disorder and my punishment…bingeing and purging is a violent act for me, a deliberate self-harming act. It is not about calories or weight; it is about beating up on me…hurt and self-loathing…hatred…I need to be punished…I must be punished…obsession, secrecy, shame, guilt, sadness, self hatred, emptiness, self-loathing, anger, climax, release, punishment, clean.”

Page 21: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Function of the Binge: Interventions

• Create a collage depicting the following: 1) What every child needs, 2) What you received, and 3) What needs your eating disorder meets.

• Write about how your eating disorder serves as a “wedge” between you and others.

• Write out What you get out of the ED and Why it “works” for you. • Identify the unmet needs related to the “what” and “why” of the

ED. • Create urge cards addressing the function of the ED. Create

Adaptive Responses to address unmet needs related to the urges. Ex: Escape related to Purging.

Page 22: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

TYPICAL TRIGGERS:• Fantasizing about forbidden foods

or food in general• Settings with copious amounts of

food or seeing food• Worries/stress• Feeling overwhelmed• Physical pain, fatigue• Alcohol consumption or being

disinhibited• Desire for pleasure• Feeling judged, blamed, rejected,

etc.• Intense or adverse emotions• Desire to rebel

• Restriction, delayed eating• Deficit of coping skills• Anxiety and tension• Cravings• Eating• Breaking ED rules• Interpersonal conflict• Distorted thinking patterns• Boredom• Opportunity (privacy)• Feeling like a failure• Trauma Intrusions• Mood instability

Page 23: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Mentalizing the Binge

• Identify Sensations, Thoughts and Feelings leading up to a binge (or specific behavior).

• Have clients connect internally, make mental notes of the S, T & F.

• Take Clients through a guided imagery journey into earliest/most prevalent memories that hold the same S, T & F as the binge holds.

• Way of IDing what binge behaviors are connected to.

Page 24: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Triggers → Beliefs, Emotions & Sensations

Page 25: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

OVEREVALUATION OF SHAPE & ACHIEVEMENT

Page 26: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

TYPES OF BINGES:

1. Stress Binge2. Hunger Binge3. Deprivation Binge4. Opportunity Binge5. Habit Binge6. Pleasure Binge7. Vengeful Binge

Page 27: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

CYCLICAL ANATOMY OF A BINGE:Phase 1: Tension Build-Up

• Restriction, delayed eating, deprivation

• Physiological distress

• Adverse/intense emotions

• Conflict

• Thought Distortions, Fantasizing about the Binge, Planning Binge

Page 28: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

CYCLICAL ANATOMY OF A BINGE:Phase 2: Acting Out

• Engaging in the binge

• Dissociation, numbing, distraction

• May include purging or other compensatory behaviors

Page 29: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

CYCLICAL ANATOMY OF A BINGE:Phase 3: Aftermath

• Exhaustion, physical and emotional; lethargic, fatigue

• Binge “Hangover”: headache, nausea, diarrhea, discomfort

• Sleeping, dissociation, avoidance, disconnection

• Resolve for Change, seeking help, Beginning of Thought Distortion

Page 30: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

OTHER WAYS OF BINGEING:• Alcohol/Drugs• Sexual Acting Out• Shopping and Purchases• Gambling• Work and productivity• On a person or a relationship• On a specific activity: a show, book, etc• Exercise

Page 31: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Assessing the Binge: Interventions

• Write a comprehensive list of the types of binges you engage(d) in. What are the patterns, triggers, & functions of each?

• List the Triggers for bingeing. Create interventions for each.

• List all of the WAYS you binge. What is the purpose of each of these?

• Map out the Cycles of your Binges. What are the patterns? Use these to apply to Relapse Prevention Plan.

Page 32: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

TRADITIONAL APPROACHES• Weight-loss & Diet Approaches• Restrictive Dieting (popular in hospitals, etc.)• Surgical interventions• Goals: Weight reduction through restrained caloric intake,

sometimes paired with exercise and anorectic medication (Romano 1995)

• Obesity Treatment Models: Focus on treating the “excess weight,” before dealing with psychological issues.

• Some Obesity Experts also believe that BED is not a public health concern, therefore not requiring the focus that “the obesity epidemic warrants” due to the consequences-hypertension, stroke and heart attack-that obesity pose.

• Self-Help Groups• 12 Step Models (OA)

Page 33: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

TRADITIONAL TREATMENT APPROACHES

• Traditional Treatment Approaches are necessary, crucial, but not sufficient. They create the opportunity for recipients to address behavioral and cognitive change necessary for long-term recovery.

• Cognitive Behavioral Therapy (CBT)• Behavioral Modification (More effective with

CO)• Traditional Dialectical Behavioral Therapy

(DBT)

Page 34: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

INNOVATIVE TREATMENT APPROACH

• DBT for Binge Eating and Bulimia (Safer, Telch & Chen, 2009)

• Focuses on Individual and Group Psychotherapy in a 20 week format

• Utilizes 3 of 4 of Linehan’s skills training modules: Mindfulness, Emotion Regulation, Distress Tolerance

• Cohesive revision of the traditional Linehan DBT for Borderline Personality Disorder

Page 35: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC
Page 36: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Diary Card

Diary Card For week beginning: Mon Tue Wed Thur Fri Sat Sun (circle one) On Date ____/____/____

This week I filled out this side of the diary card ____ each day ____ 4-6 times ____ once ____ 2-3 times

Urge to leave treatment/quit therapy (0 – 7) Before therapy session ____ After therapy session ____

Day Urge to Purge

Urge to Restrict or Binge (ID)

Urge to Exercise

Urge to Self Harm

Other Urges: Body Check, avoidance, Isolation.

Submit to Purge

Submit To Restrict or Binge (ID)

Submit To Self Harm (how)

Submit to Exercise

Submit to other Urges

Disconnected Eating How many times?

AIBs Did you set yourself up?

Food Cravings?

Preoccupied with food?

A N G E R

S A D N E S S

F E A R or A N X I E T Y

S H A M E

P R I D E

H A P P I N E S S

Rate How Much You Used Skills (0 – 7)

MON

TUE

WED

THUR

FRI

SAT

SUN

*Please rate from 0 to 7 the highest rating for the day (0 = did not experience the urge/thought/feeling, to 7 = experienced the urge/thought/feeling intensely) @USED SKILL: 0 = Not thought about or used 4 = Tried, could use them, but they did not help 1 = Thought about, not used, didn’t want to 5 = Tried, could use them, helped 2 = Thought about, not used, wanted to 6 = Used skills without trying, didn’t help 3 = Tried but couldn’t used them 7 = Used skills without trying, helped

Page 37: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Skills Used Today

Skill Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Journaling

Affirmations

Artwork/Puzzle

Containment List/Box/Imagery

Checking In

Asking for Help

Self-care

Binge/Bx Chain Analysis

Processed in Group/Sessions

Self Care

Spending time with Peers

Disclosing about Behaviors

ADL’s

Grounding

Safe Place

Leisure Time

Recovery Statements

Ban Book

Page 38: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC
Page 39: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Daily Check-In

Each day I commit to voicing my urges in an appropriate and healthy way, I commit to following my meal plan and to abstaining from behaviors. Should I struggle, l commit to struggling in a recovery-focused way with honesty. This means seeking support before I become overwhelmed and use behaviors.

_____ Abstained from Purging

_____ Abstained from Restricting

_____ Took all medications as prescribed

_____ Followed Fluid Protocol

_____ Used ACRs for Practice

_____ Used ACRs when Needed

_____ Used Voice at Meal when Struggling

_____ Formal Check ins with Staff daily

_____ Completed All Exposures and Therapeutic Assignments

_____ Practiced Using Internal and External Resources

_____ Engaged in Self-Care

_____ Journaled when Overwhelmed

_____ Socialized with Peers

_____ Asked for Support when necessary

_____ Use Resources when SH Urges are Present

Challenges from the Day:

Successes from the Day:

Goals for Tomorrow:

Affirmation for Today:

Page 40: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Distress Tolerance Scale (by Simons and Gaher) Directions: Think of times that you feel distressed or upset. Select the item from the menu that best describes your beliefs about feeling distressed or upset. 1. Strongly agree 2. Mildly agree 3. Agree and disagree equally 4. Mildly disagree 5. Strongly disagree

1. Feeling distressed or upset is unbearable to me. 2. When I feel distressed or upset, all I can think about is how bad I feel. 3. I can’t handle feeling distressed or upset. 4. My feelings of distress are so intense that they completely take over. 5. There’s nothing worse than feeling distressed or upset. 6. I can tolerate being distressed or upset as well as most people. 7. My feelings of distress or being upset are not acceptable. 8. I’ll do anything to avoid feeling distressed or upset. 9. Other people seem to be able to tolerate feeling distressed or upset better than I can. 10. Being distressed or upset is always a major ordeal for me. 11. I am ashamed of myself when I feel distressed or upset. 12. My feelings of distress or being upset scare me. 13. I’ll do anything to stop feeling distressed or upset. 14. When I feel distressed or upset, I must do something about it immediately. 15. When I feel distressed or upset, I cannot help but concentrate on how bad the distress actually feels.

Page 41: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

DTS Scoring Information:

Scoring: Item 6 is reverse scored.

Subscale scores are the mean of the items.

The higher-order DTS is formed from the mean of the four subscales.

The four scales are:Tolerance: questions 1, 3, 5Absorption: questions 2, 4, 15Appraisal: questions 6, 7, 9, 10, 11, 12Regulation: questions 8, 13, 14

The higher the score, the lower the distress tolerance abilities are.

*There is no scale for scoring; authors state it is meant to be used as a continuous measure.

Page 42: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

DBT for BED Interventions• Identify current & past TIBs, identify function of each, explore &

practice adaptive interventions to address unmet needs.• Keep daily Diary Card and monitor relationship between

urges/behaviors/skills used/events• Use daily check-in sheet to facilitate mindfulness & allow

monitoring of T,F,B,S• Create a daily recovery plan (bookends) and monitor outcome of

using plan• Complete a Behavioral Chain Analysis, Share & apply to relapse

prevention• Create Urge cards, match type of interventions to unmet

need/urge and intensity of intervention to intensity of urge

Page 43: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

INNOVATIVE TREATMENT APPROACHES: INTERNAL FAMILY SYSTEMS (IFS)

• Identify SELF as made up of “parts” aka: beliefs and feelings that define aspects of a person.

• The ED is a “part” of a person, often multiple parts, with the function of protecting the individual.

• Parts serve a function(s) to either manage, alleviate distress, or hold/protect secrets/beliefs/feelings distressing to the SELF. (Managers, Firefighters, Exiles)

• Goal: meet & understand parts of self, especially protector parts like: Restriction, Bingeing, Purging

• Goal: Allow ED parts to reveal function/role and work towards unburdening them of the role(s) keeping them in the eating disorder.

• Burdens are comprised of feelings and core beliefs that solidified from traumas & incidents or events from past

Page 44: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC
Page 45: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

INNOVATIVE TREATMENT APPROACHES: INTERNAL FAMILY SYSTEMS (IFS)

• “Unblending at the Table”• Containment/Grounding skills utilized before, during and after

meal in which the client identifies which parts are activated, present and merged throughout interactions with food.

• Before: Identifying emotions and thoughts present prior to interacting with food that would facilitate need or desire for use of ED behaviors during meal or after.

• Inviting Parts to “step back” or create space for individual to engage with food without undue distress and behaviors.

• During: Continual dialogue internally to manage feelings and distorted ED beliefs that surface throughout the meal that influence the decisions a person makes with food.

• After: Dialoguing with thoughts and feelings; AKA Parts after the meal/snack to create space.

Page 46: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Unblending at the Table

1. Explain concept of being “blended” or merged with parts. 2. Explain rationale for creating space for SELF at the table (and in general). 3. Explain value in practicing before meals and at other crucial times. 4. Evaluate what Parts often approach table with the client (guided imagery technique). 5. Teach Steps for Unblending.

Steps for Teaching Unblending

1. Focus inside and identify which emotions/beliefs (AKA Parts) are present at this moment. 2. Invite Parts to allow space for client to connect to food. 3. Teach Client about value of having parts present but unmerged. Teach about “chair,” “bench,” “swing.” 4. Techniques for Unblending (Mike Elkin Handout) 5. Need for Unblending throughout meal. 6. Explaining rationale in dialogue with Parts; reaching agreement for time and space for Parts. 7. Allowing Parts time and space at designated time for journaling dialoguing. 8. Value of bringing Parts feelings and Beliefs into later sessions/groups.

Steps for Unblending Practice for Client

1. Focus inside and identify Parts that are present. 2. Acknowledge and Welcome Parts 3. Ask Parts to take place on designated space for meal/snack time. 4. Utilize Unblending techniques if necessary. 5. Continue Unblending Dialogue throughout meal/snack. 6. Thank Parts after completion of meal/snack. Acknowledge Commitment for later Dialogue. 7. Dialogue at later Time through Journaling. 8. Engage in Resolution via check-ins, sessions or groups.

Page 47: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

INNOVATIVE TREATMENT APPROACHES: INTERNAL FAMILY SYSTEMS (IFS)

• Group and Individual session IFS work support the unblending practices.

• In IFS work, client begins to understand functions of different acting out behaviors and the exiled parts these “managers” and “firefighters” protect.

• Work to unburden “Protectors” & “Exiles” and give these parts new, helpful roles rather than protector roles that harm the person.

• Exiles unload burdens which reduces need for ED parts and other protectors.

• Can be connected back to earlier emotional experiences (see activity)

• Healing work with core experiences/dynamics can diffuse need for ED behaviors/parts

Page 48: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

IFS for BED Interventions• Write a summary of each IFS session. • Follow through on commitments made to Parts in IFS work,

integrate into daily Recovery Plan/Routine• Create a “Parts Map” as you come to understand the Parts of

You/SELF and the ED• Practice “Unblending” & use at/away from table• Practice Safe Place Imagery & work with Parts• Engage in daily dialoguing with Parts of SELF• Identify of list of Unmet Child Needs & actively set goals/exposures

to meet needs & wants.• Understand your Polarizations; write about rules & beliefs of each

Part of the ED, the feelings & the Goals of each Part (R, B, P, E, SH, etc).

Page 49: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

INNOVATIVE TREATMENT APPROACHES: EXPOSURE AND RESPONSE/RITUAL PREVENTION

• ERP is an offshoot of CBT and is effective at treating the cognitive, behavioral and often emotional end of the ED.

• Originally designed to treat OCD, SAD and GAD; now effective in treating aspects of the ED.

• Create a hierarchy of feared food items and food situations each rated based upon the level of anxiety the stimulus provokes.

Page 50: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

INNOVATIVE TREATMENT APPROACHES: EXPOSURE AND RESPONSE/RITUAL PREVENTION

• Exposures are then created from the hierarchy.• Concept is around exposing individual to feared stimuli

in a challenging but manageable fashion enough that the anxiety around the stimuli decreases over time. This anxiety reduces within the trials of the exposure and between trials.

• Exposures can be experiments, more formalized and can be recorded to show habituation; aka improvement interacting with stimuli without anxiety response.

• Exposures can be imaginal, in person, with actual food, and with actual environments.

Page 51: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

INNOVATIVE TREATMENT APPROACHES: EXPOSURE AND RESPONSE/RITUAL PREVENTION

• Exposures can involve feared food items, feared situations with food, forbidden foods, binge foods, trauma foods etc.

• Experiments can be completed with staff support, with a group, at a meal/snack.

• Goal is to complete 70% of hierarchy. • Goal is also to be able to interact with food

without engaging in ED behaviors.

Page 52: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

ANXIETY RATING SCALE

00 11 22 33 44 55 66 77

HAVE TO RESIST

TRY AS HARD AS POSSIBLE TO RESIST

CALM NO ANXIETY

NO URGES TO RITUALIZE AT

ALL

“It bothers me”

“Don’t want to do it but know it will be easier than I

think.”

A few urges to ritualize.

Anxiety is bothersome, yet

manageable.

A little bit harder to resist urges but

can still do it.

Difficult to resist

urges.

“Wish I didn’t have to do it, but can do it. Glad when it’s over!”

Come c lose to

ritualizing but can still resist.

Challenging

Unsure if able to resist ritualizing.

Very hard to

resist urges to ritualize.

Challenging

Extremely hard to resist urges to

ritualize.

Start feeling symptoms of

panic .

Near panic

Panicking

Fear of dying.

EXAMPLE:

GOING TO THE DENTIST

A few weeks before appointment. Think about not wanting to

go, but no worries, really.

Dreading going. Really don’t want to,

but know it will be ok if I go.

Think about ‘faking being sick.’ Trying to make excuses. Go to it, but glad when it’s

over.

Can’t imagine making it through the

appointment. Think about leaving in the

middle of the appointment. Strong relief when I make it.

Don’t know if I can make it. Feel some

panic symptoms starting.

Refuse to go. Feeling panicky.

PANIC Fear of dying if I go.

Page 53: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Exposure Exercise: ____________________________________________________ Trial

# Date Time Peak Anxiety Rating Elapsed Time Final Anxiety

Rating

1

2

3

4

5

6

7

8

9

10

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ERP INSTRUCTIONSGENERAL INFORMATION Pick 5-10 exposures from your hierarchy that you want to work on. Work with your adjunctive or anxiety therapist to identify the current exposures. When an exposure is crossed off choose another to replace it. Choose a variety of exposures. It is very important that you record every exposure and monitor your progress. CONDUCTING EXPOSURES: The goal of exposures is to achieve within and between trial habituation.

Within trial habituation is a reduction of your anxiety within each individual trial. Example: from a 2 to a 1.

Between trial habituation is a reduction in your peek anxiety level between trials. Example: your first trial, the anxiety went from a 2 to a 1. In the second trial your anxiety reduces from a peak of 1 to a 0. The reduction in peak anxiety levels from Trial 1 (2) to Trial 2 (1) is between trial habituation.

Conduct at least 6 (preferably more) trials of an exposure at a time before moving on to another exercise. This helps you to achieve between trial habituation and to move through your hierarchy more quickly.

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ERP INSTRUCTIONSHOW DO I CONDUCT EXPOSURES? Choose one you have decided to work on and do what it says. Example: Place Peanut

Butter on index finger. Take note of the time you begin the exposure! Once you have started the exposure (PB on Finger) rate your peek anxiety on the 0 to 7

scale (0 = no anxiety to 7 = extremely high unmanageable anxiety). Let’s say it was a 4. Continue conducting the exposure (PB on Finger) till your peak anxiety has come down by

half. Example: from a 4 to a 2. Note the time that has elapsed while conducting the exposure. Remember to continue the exposure (PB on Finger) until the anxiety has come down by at

least half. This may take several minutes or longer. If your anxiety has not come down in 30 minutes discontinue the exposure.

If your peak anxiety is a 5 or above, discontinue the exposure and move it to the appropriate anxiety level on your hierarchy.

Page 56: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

ERP INSTRUCTIONS HOW DO I RECORD EXPOSURES? Use the Exposure Record form located in your homework binder. Place the name of the exposure at the top. Follow the guidelines on the sheet. It should look similar to this: Trial

# Date Time Peak Anxiety Rating Elapsed Time Final Anxiety

Rating

1 1/15/03 4:30 PM 4 7 min. 2 After conducting a trial, wait until your anxiety has returned to 0 before conducting another

trial. This is to avoid any potential accumulation of anxiety. When reporting exposures, you will say, “touch doorknob, 4 to a 2 in 7 minutes.” Cross Off Rule: Exposures are crossed off when you have conducted at least 3 trials on two

different days for a minimum of 6 trials in which your peak anxiety rating was 0 and your final anxiety rating was 0. It is important to remember that even though you have crossed off an exposure, you are still responsible for conducting that behavior in your daily life (i.e.Touching PB in Everyday life).

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BANS Bans are a very important part of treatment, as they constitute the “response prevention” portion of exposure & response prevention. They address the compulsive behaviors you carry out to reduce your anxiety. In order for the exposure exercises to be completely effective you will need to reduce and eventually eliminate the amount of times you conduct these compulsive behaviors. The ultimate goal is to reduce these behaviors to 0 as soon as possible! Therefore, we want you to keep track of the number of times you conduct these behaviors (submits) and the number of times you wanted to conduct these behaviors but did not (resists). To record your bans we suggest you get a small hand notebook (like a reporter’s notebook). Keep track of your bans daily, from the time group ends until the time the next group begins. We suggest tracking your bans like this:

BAN: Body Checking SUBMITS RESISTS

// ////

** Remember, it is important to record your bans & reduce them to 0 as soon as possible. **

Page 58: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC
Page 59: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

CBT for ED Diary Card

Day of Week:

Date:

Time of Day:

Meal Plan:

Actual Meal: Fluids: Binge? Purge? Restrict? Rituals? Urges:B/P/R

(0-7)? Thoughts –Feelings – Events?

BF

AM

L

PM

D

HS

Page 60: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

ERP Interventions for BED• Create a hierarchy of Binge Foods, Fear Foods, Forbidden Foods &

Trauma Foods. Rate each on 0-7 or 0-10 anxiety scale. Identify situations that influence the rating.

• Work with Therapist to set up exposures.• Complete Exposures, process & use to guide further

exposures/experiments and hierarchy• Create a list of anxiety provoking body image/movement situations

and work with therapist to create experiments & exposures. • Begin moving in body & challenging avoidance or urges.• Write about all of your rituals with food & your body in detail. What

are fears around change? What is the function of each. Integrate into hierarchy as needed.

• Write about fears of allowing yourself to taste, enjoy or desire food. Write about fears of allowing yourself to connect to & “embody” your body.

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INNOVATIVE TREATMENT APPROACHES: EXPERIENTIAL and Miscellaneous THERAPIES

• Encompasses Drama and Expressive Therapies in which individuals apply cognitions and feelings into action.

• Art, music, etc.• Guided Imagery: Examples of Guided Imagery

from Group Sessions• Improv Therapy• Attachment Theory as related to the Binge• Bingeing and Body Movement

Page 62: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Parallel Arousal Systems: Attachment ~ CrittendonAttachment

• Pain• Fear• Anger• Desire for Comfort• Comfort• Bored• Tired• Sleep• Depression

Sexual• Sexual Pain• Sexualized Terror• Aggression/Submission• Romanticism• Affection• Satisfaction• Afterglow• Sleep• Numbness

Page 63: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

Parallel Arousal Systems: Attachment

Attachment • Pain• Fear• Anger• Desire for Comfort• Comfort• Bored• Tired• Sleep• Depression

Food• Starvation/Stuffing• Forbidden/Fear Foods• Anger at Food• Fantasizing about Food• Food as Comfort• Satiation• Exhaustion after R/B/P• Hangover/Sleeping• Numbness

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Bingeing and The Body• It is necessary to evaluate client’s relationships with their

bodies. • Identify the way a client feels in their body before, during

and after the binge behaviors.• Relationship between the binge and exercise• Relationship between the binge and exercise avoidance.• Challenge thought distortions about bodies and ED

behaviors. • Create exposures & interventions to help the clients create

balance and develop a healthy relationship with their bodies.

Page 65: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

BRIEF BASICS ABOUT BINGE EATING AND THE LIKE

Proposed DSM-V Definition of Binge Eating Disorder:

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances(2) A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating)

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BRIEF BASICS ABOUT BINGE EATING AND THE LIKE

Proposed DSM-V Definition of Binge Eating Disorder, cont’d:

B. The binge-eating episodes are associated with 3 (or more) of the following:

(1) Eating much more rapidly than normal(2) Eating until feeling uncomfortably full(3) Eating large amounts of food when not feeling

physically hungry(4) Eating alone because of feeling embarrassed by

how much one is eating(5) Feeling disgusted with oneself, depressed, or very

guilty afterovereating

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BRIEF BASICS ABOUT BINGE EATING AND THE LIKE

Proposed DSM-V Definition of Binge Eating Disorder, cont’d:

C. Marked distress regarding binge eating is presentD. The binge eating occurs, on average, at least once

a week for 3 monthsE. The binge eating is not associated with the

recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course of Bulimia Nervosa or Anorexia Nervosa

Page 68: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

BRIEF BASICS ABOUT BINGE EATING AND THE LIKE

Proposed DSM-V Definition of Bulimia Nervosa:A. Recurrent episodes of binge eating. An episode of binge

eating is characterized by both of the following:(1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances(2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

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BRIEF BASICS ABOUT BINGE EATING AND THE LIKE

Proposed DSM-V Definition of Bulimia Nervosa:B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise.C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once per week for 3 months.D. Self-evaluation is unduly influenced by body shape and weight.E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa

Page 70: Comprehensive Treatment of Binge Eating Disorder- Katie Thompson, LPC

BRIEF BASICS ABOUT BINGE EATING AND THE LIKERevision of DSM-IV Criteria:B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemasNonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

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BRIEF BASICS ABOUT BINGE EATING AND THE LIKE

Compulsive Overeating:•May Co-exist with BED•“consuming larger than required amounts at meal times, eating throughout the day and eating inappropriately in response to multiple cues. Often, there is little meal structure. “•“Behavior is often described as ‘grazing,’ and predictably underscore the fact that they are not generally responding to hunger. “•“Preliminary data on BED seems to highlight the relative psychological health of compulsive overeaters in comparison to those exhibiting regular bingeing behavior. “~Romano & Quinn 1995

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ReferencesAbramowitz, J.S., Deacon, B.J., Whiteside, S.P.H. (2011). Exposure Therapy for Anxiety: Principles and Practice.

New York: The Guilford Press. Albers, S. (2009). Eat Drink and Be Mindful. Oakland: New Harbinger Publications. Cooper, M., Todd, G., Wells, A. (2009). Treating Bulimia Nervosa and Binge Eating: An Integrated

Metacognitive and Cognitive Therapy Manual. London: Routledge.Fairburn, C. (2008). Cognitive Behavior Therapy and Eating Disorders. New York: The Guildord Press._____. (1995). Overcoming Binge Eating. New York: The Guildford Press.Nash, J.D. (1999). Binge No More: Your Guide to Overcoming Disordered Eating. Oakland: New

Harbinger Publications. Roth, G. (1991). When Food Is Love: Exploring the Relationship Between Eating and Intimacy. New York: Plume. Safer, D.L., Telch, C.F., Chen, E.Y. (2009). Dialectical Behavior Therapy for Binge Eating and Bulimia. New York:

The Guilford Press..Schwartz, R.C. (1997). Internal Family Systems Therapy. New York: The Guildford Press._____. (2001). Introduction to the Internal Family Systems Model. Fort Collins: Trailhead Publications..Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., Russell, K. (2011). Cognitive Behavioral Therapy for Eating Disorders: A Comprehensive Treatment Guide. Cambridge: Cambridge

University Press.