therapy

ED Therapy - Exposure and Response Prevention?

Corntney Modelewski, MA, LLPC, an active member of SMEDA and a Kalamazoo therapist that specializes in Cognitive Behavioral Therapy and DBT.  She has written this months blog article on Exposure and Response Prevention (ERP).  http://www.southwestmichiganeatingdisorders.org/directory/

     Exposure and Response Prevention (ERP) is a therapy for Obsessive Compulsive Disorder (OCD) that requires being in the presence of something that causes fear – exposure – and not avoiding the feared situation – response prevention. It can also be used during eating disorder treatment, with growing research to support its use in Anorexia Nervosa and Bulimia Nervosa. For example, in 2011 the International Journal of Eating Disorders published an article about data support ERP use to aid in weight restoration, fear of eating, learning to tolerate fear, and relapse prevention in those with Anorexia Nervosa when used as part of a treatment plan.

     With a licensed mental health therapist, a list called a hierarchy is made up of feared situations to be used as exposure tasks. Distress ratings on a scale of 0 – 100, called Subjective Units of Distress (SUD), are included on the hierarchy as well. The hierarchy gives the frame for treatment.

As an example...

Anorexia Hierarchy

Feared Situation                                                                    SUD (0-100)

Skip one day of exercise                                                                 55

Eat at a Chinese buffet restaurant                                                  95

Have friends over for dinner and eat in front of them                  100

Walk through a grocery store without buying anything                35

Fill pantry with canned food                                                           70

Eat apples with therapist                                                                 60

 

     It's common for individuals to have more than one mental health concern, especially anxiety or OCD. It helps to treat eating disorders and anxiety at the same time when doing ERP.  Kind of like killing two birds with one stone.

As an example...

Anorexia and OCD with Contamination Fear Hierarchy

Feared Situation                                                                                               SUD (0-100)

Eat sucker that has touched a grocery cart seat                                                     70

Hold a raw steak for five minutes before cooking                                                   75

Eat a bag of M&Ms off of therapist's office floor                                                     30

Eat an egg salad sandwich in the bathroom at home                                             45

Play with neighbor's dogs, eat meal without washing hands afterwards               80

 

Treatment structure will look like this:

  • One hour weekly appointments for 14 – 16 weeks.
  • Agreeing to one-half to two hours per day working on exposure tasks outside of session.
  • Getting hands-on help from the therapist to show how to complete the exposure tasks and prevent the person from trying to avoid fear.
  • Time to talk about feelings with the therapist after exposure tasks.
  • Exposure tasks outside of sessions may include help from friends, family, or members of the treatment team.
  • Tracking distress on a sheet of paper, including lessons learned from the activity, and other homework as assigned by the therapist and other treatment team members.
  • Repeating exposure tasks until SUDs go down.

     To sum it up, ERP is a process that addresses fears unique to the individual's needs. One of ERP's main goals is to help people learn skills to use when therapy is complete and encourage people to use their own ERP as needed. In other words, ERP is to help people with eating disorders to become their own ERP therapist.

Recommended YouTube video:

 

https://youtu.be/ZTwVb_3koCU

 

Sources:  (Many of these sources can be found in PubMed.)

Foa, Edna B., Elna Yadin, and Tracey K. Lichner. Exposure and Response (ritual) Prevention for Obsessive-compulsive Disorder: Therapist Guide. Oxford: Oxford UP, 2012. Print.


(Exposure and Response/Ritual Prevention for Obsessive-Compulsive Disorder: Therapist Guide, Edna Foa, Elna Yadin, and Tracey K Lichner, 2012)

Simpson, H. B., et al. (2013). Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders. Cognitive Behaviour Therapy, 42(1), 64-76. doi:10.1080/16506073.2012.751124

(Treatment of Obsessive-Compulsive Disorder Complicated by Comorbid Eating Disorders, Cognitive Behaviour Therapy, 2013, Simpson, et al)

Steinglass, J. E., Sysko, R., Glasofer, D., Albano, A. M., Simpson, H. B. and Walsh, B. T. (2011), Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. Int. J. Eat. Disord., 44: 134–141. doi:10.1002/eat.20784

(Rationale for the Application of Exposure and Response Prevention to the Treatment of Anorexia Nervosa, International Journal of Eating Disorders, 2011, Steinglass et al)

Toro, J., Cervera, M., Feliu, M., Garriga, N., Jou, M., Martinez, E., & Toro, E. (2003). Cue exposure in the treatment of resistant bulimia nervosa. International Journal of Eating Disorders, 34(2), 227-234. doi:10.1002/eat.10186

(Cue Exposure in the Treatment of Resistant Bulimia Nervosa, International Journal of Eating Disorders, 2003, Toro, et al)

Yoga as an ED Recovery Tool

  Thank you, Kristin Fiore, for providing us with this insiteful article on yoga as a part of ED recovery.

Kristin Fiore, RYT 500, is a member of the SMEDA Board, and active in helping other professionals and their clients incorporate yoga into the recovery process.    http://downdogyogacenter.com/teaching-staff/

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   Yoga has provided me with a tangible tool to facilitate acceptance, self-love, and healing in my body.  As Donna Farhi writes in her book Bringing Yoga to Life, “Through daily Yoga practice we become present to our own fundamental goodness and the goodness of others. It is the practice of observing clearly, listening acutely, and skillfully responding to the moment with all the compassion we can muster. And it is a homecoming with and in the body for it is only here that we can do all these things.” This connection of body, mind, and spirit is key as one begins to address different aspects of an eating disorder.

As a late teen suffering from an eating disorder, I found my way into treatment with a counselor and a medical doctor.  These professionals saw me independently of each other in a clinical sitting where I sat in an examination room for medical tests or in a chair for counseling sessions. In this way, I continued to feel detached from my body as there was a lack of physical participation in the process and I found it difficult to navigate the emotional connections I was making in counseling with the actual changing of habits in my body. 

It wasn’t until I began practicing Yoga that the deeper process of healing and recovery began.  I didn’t sit in a chair and talk about my feelings, I experienced them as I engaged my strength and stretched my limits. For the first time I had access to my thoughts and feelings through my body, not despite it. As movement connected with breath, I found a place inside of me that was always steady. As I developed greater awareness of the flow of prana (life force or energy) within me, I began to feel empowered and beautiful.  This quote from Nita Rubio’s essay in the book Yoga and Body Image sums it up nicely, “As you learn to move with the internal energies, you learn how to move with life’s flow. Beauty emanates from here because it is deeply rooted from within. This beauty is not one based on a standardized list of perfection. Nor does it reference an ideal. This beauty is based on feeling. Beauty is an experience.”

Yoga is an experiential practice that uses mindfulness techniques to bridge the gap between body and mind.  As we begin to feel the connection between the different aspects of our being, we open ourselves up to process, change, surrender, and accept.  The healing benefits of Yoga are many in my experience, and recent studies show Yoga may help relieve depression, anger, and anxiety and improve mood (Harvard Health Publications). Yoga also promotes greater self-awareness, self-esteem and positive body image through the cultivation of love, acceptance, non-violence, and unity. In addition, the physical poses of Yoga help the body build muscle, bone density, and aid in digestion which may be helpful during recovery from an eating disorder and for general overall health.

As we begin to explore the healing benefits of Yoga it is necessary to practice with compassion for what may arise and to seek guidance from a trusted and well-informed teacher as needed. It is important to practice in a safe and non-competitive environment.  Exploring the edge in a yoga pose in a healthy way, not by pushing the body but learning to stay with an uncomfortable sensation and find breath, may be useful when someone is feeling full and resisting the urge to purge or compensate or when they are experiencing strong emotion.  Anastasia Nevin says, “Bringing yoga into eating disorder recovery is a way to access memories, messages, and wisdom stored in the body that are not always accessible in more traditional forms of talk therapy. The ultimate goal of recovery is in fact Yoga: re-connecting and integrating all parts of the self to live a more intuitive, peaceful, and soulful life.” (Live Fit article, “The Role of Yoga in Treating Eating Disorders”)

     I have found that the routine practice of Yoga allows me to be consistent, loving, and stable in body, mind, and spirit.  Over the years of teaching and researching Yoga, I have worked with many others who also find it to be a useful therapeutic tool.  Yoga poses can be modified to suit each individual’s needs depending on where one is in treatment or recovery of an eating disorder, and the use of breathing techniques, mindful meditation, and movement make this a great holistic treatment to compliment more traditional forms of therapy. 

List of Resources:

Farhi, Donna. Bringing Yoga to Life: The Every Day Practice of Enlightened Living. San Francisco: HarperSanFrancisco, 2003. Print.

Klein, Melanie, and Anna Guest-Jelley. Yoga and Body Image: 25 Personal Stories about Beauty, Bravery & Loving Your Body. Llewellyn Publications, 2014. Print.

  Nevin, Anastasia. "The Role of Yoga in the Treatment of Eating Disorders." Sonima Live Fit. 2 July 2015. Web.

"Yoga for Anxiety and Depression - Harvard Health." Harvard Health.  Apr. 2009. Web.

ED Therapy - DBT?

This month's blog article was written by Gary Snapper, LPC, LLP, a member of the SMEDA Board and a founder of Cognitive Behavioral Solutions in Kalamazoo.  http://www.southwestmichiganeatingdisorders.org/directory/

DBT History

Marsha Linehan, creator of DBT therapy, described DBT as “a multimodal cognitive-behavioral treatment originally developed to treat chronically suicidal individuals meeting BPD criteria.”  Since DBT’s inception in the 1990s, researchers and clinicians have experimented with broadening the application of DBT to multiple mental-health disorders including OCD, Bipolar Disorder, Substance Abuse Disorders, Depression, and Eating Disorders.

 DBT Components

DBT is a high-intensity treatment program that combines aspects of Cognitive Behavioral Therapy with the concepts of Dialectics and Mindfulness.

 Dialectics is the concept that two apparently polar opposites can be true concurrently.  Dialectics help clients to avoid all-or-nothing thoughts and actions. For example, a person can be doing the best they can AND need to try harder.

 Mindfulness is associated with Eastern Religions, and portions of it have been described in most major religions.  Mindfulness is the nonjudgmental awareness of one’s internal and external experiences and states. This also can be explained as follows:  Attempting to be aware of one’s focus and gentle re-directing of the mind to the present when one notices one’s mind drifting towards judgmental thoughts or over-focusing on past or future worries.   Research has shown Mindfulness helps to reduce anxiety and to increase a sense of balance.

 DBT implements these concepts through a comprehensive regimen that requires all of the following:  1) Individual therapy, 2) Skills training,  3) After hours skills-based phone support, and 4) Weekly DBT team consultation meetings.

 DBT Theory and Eating Disorders (ED)

A cornerstone of DBT theory is that emotion dysregulation contributes to many disorders, including EDs.  Difficulty regulating intense emotions can lead to avoiding  “emotion experiencing”.  Emotions that are avoided may lead to ED symptoms, including food restriction, binging, purging, and over-exercise. DBT provides specific skills to cope with intense emotions in tandem, with a forum to learn, practice, and apply the skills.  This helps the client to replace ED behaviors with effective coping strategies. In essence, DBT teaches the ED client a new language that allows for skills-based emotion regulation in place of ED behaviors.

 Along with new coping strategies, DBT’s use of Mindfulness techniques, Dialectics, and after-hours Coaching, all apply to the treatment of ED’s, and has become a comprehensive approach for treating Eating Disorders.

 Although none of the researched eating disorder treatments are as effective as we would like them to be, research suggests that DBT rivals and/or surpasses the effectiveness of traditional CBT, which has been considered the Gold Standard for treatment of eating disorders in adults.

 A simple 8-minute video describing DBT for Adolescents can be found at: https://youtu.be/Stz--d17ID4?list=PLV9RJQek2bix34tBuHaOp12gt-sHf32yV  .

 Sources:

 Linehan, Marsha, M., (1993).  Cognitive-Behavioral Treatment of Borderline Personality Disorder.  New York: Guilford Publications.

 Linehan, M. and Chen, E. (2005). Dialectical-Behavior Therapy for Eating Disorders. In Freeman, A. Encyclopedia of Cognitive Behavior Therapy. (pp168-171). New York: Springer.

Art Therapy: Beyond the Therapist's Office

by Laura Smidchens

Art therapy is not only a way for the individual to communicate with the therapist and gain greater insight during a supervised session. It also helps individuals build skills to continue to contemplate and express themselves throughout their lives. Here are individuals’ messages...

We all have an exterior side that we show to the world and a part that we shield and protect. Art therapy helps individuals connect with, confront, and work with that private/hidden side.

The art samples shown in this volume were submitted for display in one of SMEDA’s public awareness Art Hop exhibits. The artists chose pieces that helped express their cur- rent or past relationship with their eating disorder.


Our next Art Hop exhibition will be in February, 2017. Click here for further details.