Comprehensive Treatment of ED- Erin McGinty & Laura Wood

Castlewood Treatment Center for Eating DisordersNew Innovations in Treatment:

Comprehensive Treatment of Eating Disorders, Part I

March 9, 2012

Erin McGinty, LPC, NCC & Laura Wood, RDT, PLPC, CCLS

www.castlewoodtc.com

Comprehensive Treatment of Eating Disorders…… in 90 minutes

… minus 20 minutes of Q&A

… minus 10 minutes of tangential stories

… minus one minute

… so, actually, in 59 minutes.

Eating Disorders

“These disorders which are so pervasive in our current world, illustrate that beneath the veneer of self reliance lies the core of powerlessness, alienation, detachment, self-hate and shame” 

- K.B. Walant, 1995

Initial Phase of Treatment:“Hooking” the Client and

Establishing Safety

Goals of Initial Phase:

• Building the therapeutic alliance

• Symptom containment & initial relapse prevention

• Facilitation of honesty

• History gathering & insight building

• Instilling hope

• Self-responsibility

Building the Therapeutic Alliance

• Identify and validate fears

• Anticipatory guidance about what to expect

• Demonstrating respect and appreciation for the eating disorder

• Collaborative treatment planning and goal setting

• Exploring and processing previous treatment experiences

Symptom Containment & Initial Relapse Prevention

Symptom Containment & Initial Relapse PreventionInitial Relapse Prevention:• Urge Cards• Behavioral Contracts• Diary Card*• Behavioral Chain Analysis*

*Recommended Reading:

Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and bulimia. New York, NY: The Guilford Press.

Symptom Containment & Initial Relapse Prevention

Symptom Containment & Initial Relapse Prevention

Facilitation of Honesty

• Each evening, take inventory of how your eating disorder has been deceptive, evasive, and/or avoidant. Process in individual session and present in group daily

• Dialectic: Acceptance and change

History Gathering & Insight Building

Pertinent Questions in History Taking:• Sense of attachment with primary caregivers

• Messages received about femininity/masculinity

• Puberty

• Messages received around food, weight, and shape

• Exhaustive history of the eating disorder

History Gathering & Insight Building

The Timeline Assignment: Create a timeline, in narrative or timeline form, that outlines significant events, relationships, and developments from birth up until your current age. Include the following:

• Information about your family of origin

• Any incidences of trauma (e.g. physical, verbal, emotional, sexual, developmental)

• The onset and progression of your eating disorder, including any periods of recovery or remission

• Treatment history

History Gathering & Insight Building

A Typical Day in Your Eating Disorder: Write a narrative about a typical day in your eating disorder; be sure to include events, thoughts, feelings, and behaviors, and be as exhaustive as possible.

History Gathering & Insight Building

The Worst Day in Your Eating Disorder: Consider the worst day that you can recall in your eating disorder, and write a narrative about all of the events, thoughts, feelings, and behaviors encompassed in that day.

History Gathering & Insight Building

Children's Needs: Make a collage about what every child needs on one side, and what you received on the other.

Instilling Hope

• “Hope Merchant”

• Notebook of Hope

• Recovery Network

• Create and art piece that depicts your eating disorder part, and an art piece that represents your recovery part

Self-Responsibility

• Feelings and Communication packet

• Helping clients to be able to ask for help and exploring stuck points in the process

Middle Phases of Treatment:Breaking Ground (Denial) &

Building a Foundation

Goals of Middle Phases:

• Identify the functions of eating disorder behaviors• Finding alternatives solutions and relapse prevention• Exploring the impact of messages received• Getting to know Protectors, healing Exiles• Connecting to affect and the body• Identification of guilt, shame, and self-hate• Understanding polarities• Renegotiating the relationship with the food: It’s not

about the food!

Identify the Function of the Eating Disorder• The eating disorder is a survival strategy

• Every eating disorder behavior serves a function, and that function changes over time

• The eating disorder is…

Identify the Function of the Eating Disorder

Identify the Function of the Eating Disorder

Identify the Function of the Eating Disorder• The 10 functions of an eating disorder have to be

understood in order to give them up, they are different for every person, and they will change over the course of treatment

• Playing the Eating Disorder in Expressive therapy

• Ask the eating disorder to write the client a letter expressing all of the ways it has protected him/her and then Ask the client to write a letter of gratitude to the eating disorder in response

Identify the Function of the Eating Disorder• Create an art piece depicting what your eating

disorder says that you can’t• Write about what your eating disorder communicates

to your family, to others, and the world at large• Write about how your eating disorder is your primary

relationship• Write about the metaphors for your eating disorder

and how it is similar to the relationships you have with people (e.g., where else in life do you restrict, binge, or purge?)

Finding Alternative Solutions & Relapse Prevention• Every urge signals a need• Adaptive coping responses geared toward meeting the

needs without using the eating disorder to do so• Relapse prevention plan• Write out your next eating disorder relapse• Create a collage of what you wanted to purge when

you purged last night. Include thoughts, feelings, etc. What other alternatives could you have used to “purge” these thoughts and feelings? Share in individual session and in group

Exploring the Impact of Messages Received• Mirror/Body Image/IFS Exercise• After writing narratives, have clients identify “the

beliefs you formed about yourself, others, and the world at large” as a result of an event, relationship, etc.

• Write it, share it, draw it, expressive, cohesive narrative

• Write about the messages you received from your mother/father about femininity/masculinity, gender, and sexuality.

Exploring the Impact of Messages Received• Placement Activity: Have clients create a collage on a clear

plastic plate about the messages they received growing up around food. When complete, have clients share in a group about these messages. Then, give each client a placemat in group, and have each group member write a positive affirmation on the placemat; peers can write about their wishes or hopes for each other. When complete, have clients put the placemats underneath the plates, and talk about the metaphor that—underneath all of the messages they received around food growing up—the core of each one of them is positive (represented by the placemat)

Exploring the Impact of Messages Received• Write about the messages you received about

emotions such as anger, sadness, guilt, shame, happiness, and fear growing up. How did you observe these emotions being expressed in your family of origin? What beliefs did you develop about emotions as a result?

Getting to Know Protectors, Healing Exiles• Expressive therapies

• Internal Family Systems model

Connecting to Affect and the Body

• Debunking common myths about feelings

• Exploration of fear around expression of emotion

• Affect tolerance

Identification of Guilt, Shame, & Self-Hate• Psychoeducation

• Bibliotherapy:– “Facing Shame: Families in Recovery” (Fossum)– “Healing the Shame that Binds You” (Bradshaw)– “There is Nothing Wrong With You” (Huber)– “Compassion and Self-Hate” (Rubin)

Understanding Polarities

• Two polarized parts always protect an Exile

• How to avoid polarizing the client

• Write about the rules and beliefs of each part of your eating disorder (restrict, binge, purge, exercise, etc.), the feelings associated with each part, and the goals of each part.

Renegotiating the Relationship with the Food (It’s not about the food, but it is about the food!)

• Deconstructing the meaning of food

• Therapeutic meals

• Exploration of rituals at the table: Write about all of your rituals at the table in exhaustive detail. What is the function of each? What are the fears around change?

• Exposure and response prevention therapy

• Write about your fears of allowing yourself to taste, enjoy, and desire food

Middle-Late & Late Phases of Treatment:

Self Development and Integration

Goals of Middle-Late & Late Phases:

• Acknowledgement of grief and loss• Reduction of self-hate, building of self-compassion

and love• Building autonomy & life skills• Femininity and sexuality• Transferring secure attachments in treatment to self• Building relationships with others

Acknowledgement of Grief and Loss

• Elizabeth Kubler-Ross model

• Grieving the loss of the eating disorder

• Write a goodbye letter to your eating disorder

Reduction of Self-Hate, Building of Self-Compassion and Love

“You yourself, as much as anybody in the entire universe, deserve your love and compassion.”

- Buddha

Reduction of Self-Hate, Building of Self-Compassion and Love• Talking about shame reduces shame= breaking

the silence

• Trump card

• Internal Family Systems and compassionate self-witnessing/unburdening

Building Autonomy & Life Skills

• Make a list of 10 things that you do not know how to do that are basic life skills (Toothbrush story)

• Write about the life skills you possess but feel insecure about, the life skills you know you do not have, and the fears around dealing with specific things that create anxiety within

• Meal and snack outings• Peer and solo outings• Time for self (being alone with yourself)• Life Skills Assessment

Femininity/Masculinity, Sexuality, & Intimacy• Complete the following sentences: “Love is…,” “Pleasure

is…,” “Indulgence is…,” “Intimacy is…”

• Complete the following sentences: “Relationships are…” “Love is…,” Sex is…,” “Woman are…,” “Men are…”

• One’s relationship with oneself: “Doing the U-Turn”Bibliotherapy Recommendations:- Be the Person You Want to Find: Relationship and Self-Discovery

(Huber)

- You Are the One You’ve Been Waiting for, Bringing Courageous Love to Intimate Relationships (Schwartz)

• Create a list of 10 qualities in women/men who you admire

• Looking at art: Women in art

Femininity/Masculinity, Sexuality, & Intimacy

Femininity/Masculinity, Sexuality, & Intimacy

Femininity/Masculinity, Sexuality, & Intimacy• Create a collage of the woman/man you would like to become

• Write about what a healthy sexual relationship looks like

• Reflect upon and write about your patterns in your adult and romantic/sexual relationships. Consider how these connect with childhood experiences. Share with your therapist and in group

• Write about the overt and covert messages you received from your mother/father growing up about femininity/masculinity. Consider how this has shaped your ideas of what it means to be a woman/man, and what you believe about yourself as a woman/man as a result. Share in individual session and in group

Transferring Secure Attachments in Treatment to Self• Working with child parts

• Role play what is normative versus dysfunctional

• Built-in practice time

• What parts of ones self are still treating the child parts like the ones who caused the initial hurt—why?

Building Relationships with Others

• Write about what aspects of yourself are positive and beneficial in your relationships with others, and what you see as the negative aspects of yourself in your relationships

• Mentalizing (keeping mind-in-mind)• Group interview• Role rehearsal

Building Relationships with Others

• Develop a buddy system with ______. Challenge each other daily to be spontaneous, pursue non-productive and pleasurable activities, mindful, etc.

• Write about times you said “yes” even though you wanted to say “no” (or already had said “no”). What fears did you have about saying “no,” and what excuses did you say to yourself in order to say “yes” instead of “no?”

The End Goal…

“Recovery is not just the absence of symptoms…it is the presence of a full life as evidenced by the ability to be human.  A truly recovered life will reflect spontaneity, freedom, the ability to breathe, to have wants, needs and desires, knowing that the quest for perfection is an unattainable illusion.  Having the ability to embrace the feminine, having close intimate relationships, and it is being aware of the tears in your eyes (whether out of intense or subtle sadness – or out of joy – or from a flicker of utter gratefulness) and then to allow your tears to flow freely.  It is a life in which decisions and choices are made more from self and less from a shame and fear based prison.  It is a life where you fully experience pleasure, joy, and passion and believe and know it is good to desire and enjoy sex…”

- Theresa Chesnut, Therapist