Participating on an FBT Team

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Family-based treatment (FBT) is the leading evidence-based treatment for teens with anorexia nervosa and bulimia nervosa. While in an ideal world, every person with an eating disorder would have access to a full treatment team including a therapist, a dietitian, a medical doctor, and a psychiatrist, FBT calls only for a therapist to guide the parents and a medical doctor to manage medical needs. A dietitian is not required, but I have found that a dietitian who works primarily with the parents can provide valuable guidance. Sometimes there are other treatment providers. If there are multiple providers, it is important that team members are in agreement about treatment philosophy and goals. Otherwise, a nonaligned team can potentially be detrimental.

Overview of FBT (3 phases)

Family-based treatment is a manualized therapy, presented in a “manual” with a series of prescribed goals and techniques to be used during each phase of treatment. It focuses on empowering the parents to play a central role in their child’s recovery, using contingencies to reverse malnutrition, increase weight, and eliminate symptoms including restrictive eating, bingeing, purging, and overexercise. FBT is based on five principles:

  • Agnostic view of illness—there is no need to find a cause or underlying issue that caused the illness.
  • Initial symptom focus—the focus is on reversing malnutrition and eliminating other eating disorder behaviors.
  • Family responsible for refeeding/addressing behaviors—parents are empowered to take charge of all meals—including planning, cooking, serving, and supervision—to ensure they are consumed as well as preventing other behaviors such as bingeing and purging.
  • Non-authoritarian stance—the therapist is a guide and partner that empowers parents to help their child.
  • Externalization of illness—the illness is seen as an external force that is threatening the child’s life.

FBT consists of three phases:

  • Phase 1: Parents are fully in charge of and supervise all meals until behaviors have largely ceased and weight is nearly restored.
  • Phase 2: Once behaviors are largely eliminated, weight is nearly fully restored, and meals are going smoothly, parents gradually hand back some control of eating to the adolescent in an age-appropriate manner.
  • Phase 3: Once the adolescent has resumed age-appropriate independence over their own eating, the focus of therapy turns to other adolescent development issues, any remaining comorbid problems, and relapse prevention.

When to Add Other Providers

Many parents are incredulous that family-based treatment is a standalone treatment. It is primarily a behavioral treatment focused initially on a brain rescue and then on eliminating symptoms. Medical providers unfamiliar with FBT and treatment centers that insist on having complete teams may pressure families to add an individual therapist for the patient with the eating disorder to the team. This is not always advisable. Sometimes, in FBT, less is more; the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed: issues with depression and self-esteem resolved during FBT treatment.

Family-Based Treatment Teams

Dietitians

For families that want to work with a dietician who is familiar with FBT, my colleague, Katie Grubiak, RDN, and I have worked out the following successful protocol. In Phase 1 of FBT, the dietitian is only included when needed and only meets with the parents. This helps to empower the parents and prevents the dietitian from inadvertently colluding with the eating disorder. When a dietitian meets the teen too soon, we have found that the eating disorder tries to ally with the dietitian and the teen spends the time trying to negotiate for preferred “eating disorder foods.” We find it more effective to avoid giving the eating disorder that voice. Parents—who have after all been feeding their child since birth—know what their teen truly likes and can avoid being manipulated by the eating disorder.

The situations in which I have found the dietitian to be necessary include the following:

  • The adolescent has another issue that necessitates dietary restriction such as celiac disease, diabetes, or a food allergy.
  • The teen’s eating has been extremely restrictive and the range of foods at the outset is extremely small
  • There is concern about medical issues such as refeeding syndrome and intake must be more closely measured
  • There is a history of an eating disorder in a parent and they feel insecure about challenging their child’s eating
  • The parents are highly anxious and unusually overwhelmed and benefit from greater support and direction from a dietitian.

Towards the end of Phase 2, I find it very valuable to have the dietitian begin meeting individually with the teen. This can be helpful in trying to increase the teen’s responsibility for their own recovery. The dietitian can also bridge the gap between the parents being in charge and the child being in charge by temporarily overseeing the child as the parents relax control. We have found it very beneficial for the dietitian to help the adolescent work on determining portion sizes and exposure to fear foods and eating in different contexts and to have some initial meals without the parent and see how they do.

Individual Therapists

Resources are limited: families have limited finances and there are not enough eating disorder providers to meet the demand of people with eating disorders. I believe that in most cases we should wait until Phase 2 of FBT before adding additional therapies. In this way, we can see what issues resolve on their own when weight is restored. After a teen has resumed regular eating and has nutrition sufficient to support higher level brain functioning, individual therapy can be added if it is needed. This is the point in therapy at which the adolescent is likely to be more receptive and able to benefit from individual therapy.

Having worked alongside several individual therapists providing individual therapy while I provided FBT, I have some suggestions that can help keep all providers on the same page and maximize benefits to the family. The most common scenarios I have encountered include the following:

  • Dialectical Behavior Therapy (DBT) therapist addressing emotion regulation
  • Exposure and Response Therapy (ERP) therapist addressing obsessive-compulsive disorder (OCD) or symptoms
  • Adolescent therapist addressing comorbid anxiety, depression, self-esteem, or interpersonal issues

The biggest problems I have encountered occur when individual therapists focus on coaching the adolescent to individuate and stand up to parents. This is inconsistent with the early stage of FBT, which requires the parents to be empowered to make all food decisions for an adolescent who is incapable of making reasonable decisions about food given their brain starvation. In FBT we don’t encourage independence in eating until the teen shows they can handle it. Similarly problematic are providers who educate the adolescent about his parents being too “enmeshed.”

On the other hand, I have had great experiences with individual therapists who understood that keeping the parents in charge of eating was crucial for the teen’s recovery. Instead, these therapists worked to empower the parents to help the teen eliminate other obsessive behaviors such as compulsive exercise. I have also worked with successful  DBT teams that focused on teaching the adolescent skills to manage her distress while not attempting to question or undermine the parents’ authority over food decisions.

Advice for The Individual Therapist

My advice for the individual therapist:

  • Don’t blame parents for causing ED
  • Don’t disempower the parents
    • Don’t question parents being in charge of food
    • Don’t suggest compromising on food choices
  • Don’t describe parents as enmeshed—instead, reinforce their instincts in attending to a very ill child
  • Don’t focus on empowering the adolescent to share frustrations about parents being in charge
  • Do focus on empowering the adolescent to demonstrate recovery behaviors even if it is for show (“acting as if”)
  • Help the adolescent to develop coping skills to use when the FBT process is upsetting to them
  • Respect parents’ choice to stop activities until they eat (delineate consequences before meals)
  • Help the adolescent fill their life with other things
  • Remind the adolescent that the parents will be able to give back control as the adolescent demonstrates readiness
  • Let the adolescent vent about their frustration over parents being in charge
  • Acknowledge that although there are many things the teen can do on their own that are developmentally appropriate, at the present time eating independently is not one of them

 

Sweatin’ for the Wedding: Say, “I don’t.”

Sweating for the Wedding? Say: I Don’t.
Image by rawpixel on Pixabay

by Carolyn Hersh, LMFT

In November of 2018, my boyfriend proposed to me. It was one of the most exciting days of my life thus far. With a proposal comes the next exciting chapter: wedding planning. For many brides-to-be, this entails finding that perfect gown.

Sadly, although not surprising, once I got on bridal mailing lists, I learned I was also being targeted by gyms for “Bridal Boot Camps” and “Sweatin’ for the Wedding.” The weight loss industry found yet another way to weasel their way into a life event that should have nothing to do with changing one’s body.

Why is it that you could be with someone who you love for a certain amount of years, and suddenly the moment they place a ring on your finger you need to change your body? Why does looking beautiful equate to weighing less?

Unfortunately, it has become the norm in our culture to experience pressure to lose weight for special events. A friend once shared that when she was dress shopping her consultant actually wrote down smaller measurements because “all brides lose weight.” When my dress consultant mentioned letting her know if I lose weight, my initial thoughts were, “Are you telling me I need to lose weight? Am I supposed to lose weight? What if I like my body where it is? What if I want to gain weight?”

Granted, our bodies can change. But, hearing about weight loss, exercise programs, and diets specific for the big day can be detrimental to our physical and mental health. The diet industry has found another market and doesn’t care how it impacts the people getting married.. Wedding planning can be stressful enough with trying to create a special day without the added pressure to create a “perfect” body.

But, here is the thing. Your fiance asked to marry you not because of what you’ll look like on that one specific day, but because they are in love with you and everything about you. Getting married is about making a commitment of love to one another. Your wedding day should be a celebration of that.

As brides or grooms, we should dress up and present ourselves the way we want to on this day but, it should not be at the expense of our health and well being. Remember what this day is about. Your wedding is not about the celebration of the size of your body but about the love between you and your significant other and making a commitment to one another.

What to do Instead of “Sweatin it”

Here are some tips I have developed to use myself and also with my clients who were wedding dress shopping:

  1. Buy a dress that fits you now. Don’t buy something a size smaller. Don’t use words like “my goal size” or “I’ll be pretty when I fit into this.” Fighting your body to go to a size it isn’t meant to be is only going to add more frustration, stress, and sadness. If the person selling you a dress keeps harping on “when you’ll lose weight” or “all brides lose weight” speak up and tell her that isn’t your plan. You do not have to be a victim of diet culture. Buy the dress that makes you feel pretty right now. Also, do not forget that many dresses you try on are just sample dresses. It’s okay if it doesn’t fit perfectly when you try the dress on. The one you get will be tailored to your already beautiful body,
  2. With that, remind yourself of the things that not only make you look beautiful but what makes you feel beautiful. One of my bridal consultants asked me when picking out a dress, “Do you want to feel whimsical? Do you want to feel like a princess? Do you want to be sexy vixen?” Wedding dress shopping became ten times more fun when I could close my eyes and imagine what style of dress would make me feel the most beautiful.
  3. Write down what you want to feel on your wedding day. Write down your hopes and excitements for this day. Think about what memories you want to hold onto.  While the idea of “looking perfect” in your wedding photos may be a strong drive to engage in diet culture, think about what those photos are truly capturing. Most likely, you’ll want to remember this as a day of celebrating love and new beginnings with your partner.
  4. It’s okay to exercise and it is okay to eat. It’s okay to follow your normal routine, As you plan for your wedding continue to follow your intuitive voice. For many people, weddings take months if not years to plan. Do not remove fun foods out of your diet for the sake of just one day. Listen to your body when it comes to exercise. Exercise because you want to give your body the gift of movement, but know it is okay to take days off too. Exercise should not be a punishment to your body.

In Conclusion

You do not need to lose weight for your wedding day. Ultimately, remember what this day means to you and your partner. Your wedding dress should be the accessory to the already amazing you. You know, the person that your partner wants to spend the rest of his or her life with. So, when it comes to “sweatin’ for the wedding,” say, “I don’t.”

Weight Gain in Bulimia Recovery

by Elisha Carcieri, Ph.D., a former associate therapist at EDTLA

Weight Gain in Bulimia RecoveryOne of the hallmark features of eating disorders is placing a high value on body weight and shape in determining one’s self-worth. In addition, people with eating disorders often believe that body shape and weight can be controlled through diet, exercise, or, in the case of bulimia nervosa, purging. Individuals with bulimia nervosa purge in an attempt to eliminate calories consumed (which is actually ineffective), empty or flatten the stomach, modulate mood, or as a self-imposed negative consequence for binging. Bulimia carries serious mental and medical health risks. The road to recovery from bulimia usually involves (at least) outpatient therapy with a qualified mental health professional such as a psychologist.

Bulimia Treatment

Cognitive behavioral therapy (CBT) is the most well-researched and effective treatment for bulimia. Therapy begins with an initial goal to immediately stop purging, monitoring weight and food intake and implementing regular eating, which usually looks like three meals and two snacks spread out over the course of the day. Over the course of therapy, the patient and therapist address the various factors that keep the eating disorder going including the over-evaluation of weight, shape, and one’s ability to control these factors, dietary restraint and restricting food intake, and mood and anxiety-related factors associated with the eating problem.

Most patients with bulimia nervosa present to treatment at a weight that is in a “normal” range for their height. This is in contrast to those with anorexia nervosa, who are typically underweight. Despite being at a normal weight, the characteristic weight and body dissatisfaction associated with bulimia is strong at the beginning of treatment, and patients believe that they are controlling their weight via their purging behaviors. People with bulimia often restrict food intake in various ways, only to eventually binge and purge. Because treatment involves eating meals at regular intervals without purging, a common fear at the outset of treatment is whether changing eating patterns will result in weight gain. The answer is…maybe.

For most patients with bulimia nervosa, treatment will not result in a significant change in weight. However, some patients may gain weight and a small percentage of patients will lose weight as a result of eliminating binge eating. It is not advisable for patients in recovery from an eating disorder (or anyone, for that matter) to have a specific goal weight in mind. Focusing on weight loss is incompatible with CBT strategies to eat balanced and sustaining meals at regular intervals. Weight may fluctuate over the course of treatment, and, when a person is eating normally, the body naturally gravitates toward a biologically determined weight that is largely out of our control. Indeed, learning to focus less on body weight as a determinant of achievement or self-worth is a valuable treatment goal.

What is Weight Suppression?

Some patients with bulimia may start treatment at a weight that is in the normal range for their height or even on the high side but low in the context of their adult weight history. Weight suppression is maintaining a body weight that is lower than an individual’s highest adult weight. Recent research has begun to shed light on the effects of weight suppression on eating disorders, especially bulimia. Bulimia is often kick-started with a desire to lose weight and attempt at weight loss through dieting. Research has demonstrated that living at a suppressed weight has a significant impact on bulimic behaviors, increasing the likelihood of binge eating (potentially through a brain-based biobehavioral self-preservation mechanism), and subsequently purging. Relatedly, and counterintuitive to what people with bulimia believe about their ability to control their weight, weight suppression is associated with weight gain over time, which further promotes dieting and purging given the strong aversion to weight gain that most sufferers experience.

Will I Gain Weight?

So, what does this mean for treatment and recovery? For patients seeking treatment, this means that yes, you may gain weight, especially if your weight is lower than a previous higher adult weight. This may feel scary, especially at first. Clinicians may even feel uncomfortable having this discussion and feel tempted to reassure patients that they will not gain weight. However, this message is inconsistent with what we now know about weight suppression and reinforces the idea that gaining weight is to be feared and avoided at all costs. Gaining some weight may actually be the key to breaking the cycle of binging and purging, which is much more valuable than maintaining a lower weight.

Greater weight suppression is associated with persistent bulimia symptoms and relapse, so gaining some weight may actually increase the likelihood of recovery from bulimia and also serve as protection against future eating disorder relapse. Weight gain may not just be a side effect of treatment, but it may be an appropriate treatment goal if you have bulimia and are living at a suppressed weight, just as it is an important goal for someone recovering from anorexia.

In Conclusion

If you have had previous treatment, but are still binging and/or purging, it is important to explore whether weight suppression might be a contributing factor. You can discuss whether gaining some weight might be appropriate with your clinician. Understanding the role of weight suppression on maintenance of the eating disorder should serve as motivation to continue treatment and work toward managing negative feelings related to weight gain. Indeed, it is helpful to explore the motivation behind the importance of thinness or maintaining a certain weight and challenging fears associated with gaining weight. You may find that living at a slightly higher weight, once acceptance is achieved, can be much less stressful and time-consuming than forcing your body to weigh less than it is biologically programmed to.

References

Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York, NY: Guilford.

Juarascio, A., Lantz, E. L., Muratore, A. F., & Lowe, M. R. (2018). Addressing weight suppression to improve treatment outcome for bulimia nervosa. Cognitive and behavioral practice, 25(3), 391-401.

Lowe, M. R., Piers, A. D., & Benson, L. (2018). Weight suppression in eating disorders: a research and conceptual update. Current psychiatry reports, 20(10), 80.

 

Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716). Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she is also a proponent of alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size. She is currently living in Charleston and working as a full-time mom to her two sons, ages 3 and 1. Dr. Carcieri is a member of the Academy for Eating Disorders (AED). She can be reached via email at dr.elishacarcieri@gmail.com.

Is the (Eating Disorder) Treatment Your Child is Getting FBT?

When new families talk to me about Family-Based Treatment (FBT), I often find that they are confused about what it is and what it isn’t.

FBT is a type of evidence-based treatment for adolescent eating disorders. This treatment was developed at the Maudsley Hospital in London in the 1970s and 1980s; Doctors Lock and Le Grange manualized it into its current form in 2001. Because of its name, FBT is often confused with more general “family therapy.” Be careful, because these are not the same thing—while both involve the family, FBT is a very specific, behaviorally-focused therapy.

While a treatment that includes some elements of FBT—but falls short of the full manualized treatment—may work for some eating disorder cases, it may not work for more difficult cases. When FBT doesn’t work it is important to know whether the child has had an adequate course of the true treatment in its evidence-based form. This can be tricky—in the field of psychotherapy, most therapists identify as eclectic, meaning they adhere to no single therapeutic orientation but combine techniques from several (just scroll through any Psychology Today therapist profile to get a taste for how many different theoretical approaches most therapists endorse). We don’t yet know which elements of FBT are critical to its efficacy and make it such a successful treatment. This would take expensive dismantling studies in which different partial treatments are tested against each other. Except for studies documenting a separated FBT (where only the parents attend sessions), no such study has been cited in the literature. Until we have good evidence that suggests otherwise, treatments that stay true to the original, already-tested treatments are the safest bet.

I once worked with a patient with panic disorder who had had previous treatment. He told me that his previous therapist had conducted cognitive-behavioral therapy (CBT), widely accepted as the best evidence-based treatment for panic disorder. When I dug deeper, I found that his therapy had included no exposure to the sensations of panic—considered to be the core element of CBT treatment for panic disorder.  Instead, the treatment had focused on discussing his anxiety thoughts—a very different protocol. From this experience I learned to inquire carefully about the treatment my patients have previously received before accepting that it cannot work for them.

So it is with Family-Based Treatment. Sometimes parents tell me that they think they tried FBT but are not sure. If your child was treated in an academic center, it’s more likely they got the evidence-based treatment of FBT in its full form. However, some parents who tell me that FBT didn’t work also tell me:

  • They did FBT on their own, with no therapeutic support
  • They had meals with their child, but that the therapist met primarily with the adolescent alone
  • They didn’t supervise all meals because their child resisted it. 

In each of these situations, it is obvious to me that the treatment is not what I would consider FBT. And while it is true that including some aspects of FBT or even a “watered down” FBT may be better than no FBT or parent inclusion at all, it’s important to know whether your child had the real thing or not, especially if they end up needing more or different treatment.

Often, parents who tell me they struggled with renourishing a child on their own find that things go much better once they started working with me or another therapist. That’s not to say that parents should never try to renourish a teen on their own—just that supporting a child with an eating disorder is extremely hard work and best done with the support and guidance of a professional at their side.

Signs Your Child Received FBT

Accordingly, I created the checklist below for parents to determine whether the treatment their child received (or is receiving) is really FBT. To how many of the following statements can you answer “YES” (the more the better)?

  • My therapist received training through the Training Institute for Child and Adolescent Eating Disorders.
    • The basic training is a 2-day workshop. Have they attended one?
    • Have they received or are they receiving clinical consultation or supervision by a staff member of the institute?
    • Are they certified in FBT by the Training Institute (meaning they have completed the 2-day training and received 25 hours of consultation by a staff member around their treatment of 5 patients)?
  • My therapist owns, seems familiar with, and refers to the FBT treatment manual.
  • My therapist refers to and acknowledges the three phases of FBT:
    • Phase 1 —full parental control
    • Phase 2 — a gradual return of control to the teen
    • Phase 3 —establishing healthy independence
  • My therapist is familiar with the work of Drs. James Lock and Daniel Le Grange, developers of the FBT treatment.
  • My therapist adheres to the five principles of FBT:
    • I was specifically told I was responsible for restoring my teen nutritionally and interrupting behaviors that interfere with recovery (including bingeing, purging, and overexercise). I was specifically told I was responsible for planning, preparing, serving, and supervising all meals.
    • I was told we don’t know for sure what causes an eating disorder and it doesn’t matter.
    • Initial attention of treatment focused solely on restoring health including weight gain and stopping eating disorder behaviors.
    • Rather than being given prescriptive tasks, I was empowered to play an active role and to discover those strategies that worked best for my family and the child whom I know best.
    • I was taught to externalize the illness and see it as an outside force that has hijacked my child, threatens his or her life, and makes my child do things he or she wouldn’t normally do. My child did not choose the eating disorder.
  • I have had a family meal at the therapist’s office.
  • My therapist spends most of the time with the full family, meeting only briefly with the adolescent alone at the beginning of the session (or in the case of “separated FBT,” all of the time with parents).
  • My therapist or another member of the treatment team tracks my child’s weight and gives me feedback after every weigh-in on how he or she is doing.
  • I was specifically told I am responsible for supervising all meals and snacks to ensure completion. If purging has been a problem, I was told to supervise the child after eating to prevent purging.
  • If my child has been exercising excessively, I was told to prevent this.
  • After weight was restored and bingeing and purging and other behaviors had ceased, my therapist guided me in gradually returning my teen control over their own eating.
  • I was told it was important to be direct with my teen about eating adequate amounts of food.
  • My therapist discusses the importance of both “state” and weight to recovery—meaning my therapist explains that weight recovery is a step towards psychological recovery, but not an end goal in itself.

Dead giveaways your child did not get FBT

Below are some indicators that your child might not have “gotten FBT” and might be receiving some conflicting messages:

  • I have been told that we, the parents, had caused the eating disorder.
  • My therapist spends the majority of therapy time alone with the teen.
  • My therapist spends a lot of time talking about the past and reasons my child wanted, needed, or otherwise developed the disorder.
  • A dietitian has met alone with my teen and given him or her nutritional recommendations.
  • My child has been given a meal plan.
  • I have been told that it is an option to not supervise all meals or prevent all purging.
  • The FBT therapist has provided individual CBT, DBT, or ACT with the teen during the weight restoration phase.
  • I have been told from the start of treatment to “not be the food police” (in FBT, this might happen toward the end of treatment, or in Phase 2 with an older teen).
  • My child has been in charge of making his or her own meals from the outset of treatment.

Summary

In conclusion, FBT has been proven to be the most effective treatment for adolescents in clinical trials. That said, not every treatment works for everyone. In my opinion, it is best to start with something that has a backing and then try something else if that doesn’t work. When you have sought out an evidence-based treatment, it’s important to make sure you’re getting the treatment in its researched form.

ARFID talk for LACPA Professionals in Los Angeles

ARFID talk LACPA Jennifer Thomas, Ph.D.
Harvard Health Publications, Jennifer Thomas

Date:  Thursday, January 18 at 7:30 PM

Presenter:  Jennifer Thomas, Ph.D.

Title: Avoidant/restrictive food intake disorder: Assessment, neurobiology, and treatment

Description: Avoidant/Restrictive Food Intake Disorder (ARFID) was recently added to the Feeding and Eating Disorders section of DSM-5 to describe children, adolescents, and adults who cannot meet their nutritional needs, typically because of sensory sensitivity, fear of aversive consequences, and/or apparent lack of interest in eating or food. ARFID is so new that there is currently no evidence-based treatment.  This presentation will discuss how to recognize and diagnose ARFID, share preliminary findings from an ongoing NIMH-funded study of its neurobiological underpinnings, and describe a new cognitive-behavioral treatment currently being evaluated in an open trial.  

Bio:  Dr. Jennifer Thomas is the Co-director of the Eating Disorders Clinical and Research Program at Massachusetts General Hospital, and an Associate Professor of Psychology in the Department of Psychiatry at Harvard Medical School. Dr. Thomas’s research focuses on atypical eating disorders, as described in her books Almost Anorexic: Is My (or My Loved One’s) Relationship with Food a Problem? and Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. She is currently principal investigator on several studies investigating the neurobiology and treatment of avoidant/restrictive food intake disorder, funded by the U.S. National Institute of Mental Health and private foundations.  She is also the Director of Annual Meetings for the Academy for Eating Disorders and an Associate Editor for the International Journal of Eating Disorders.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to:  drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

 

 

Sleep: Monitoring and treatment of insomnia without drugs

insomnia treatment without drugsBy Elisha Carcieri, Ph.D.

“A ruffled mind makes a restless pillow.” Charlotte Bronte

In our self-obsessed culture, monitoring and tracking heartbeat, steps, exercise, food intake, and sleep is commonplace. My sister has recently been tracking her sleep using an app on her smartphone, and she encouraged me to do it too. My first response was, “Why? I know I’m sleep deprived. I don’t need an app to tell me that.” I was still nursing my baby once a night at the time and I was pretty positive this was negatively impacting my sleep and my ability to function in general. Skeptical, I downloaded the app and started it each night before bed for about a week. The application’s primary measure of sleep quality is called ‘sleep efficiency,’ which is the amount of time you are asleep divided by the amount of time you are in bed, and is represented as a percentage. This is the same measure of progress I use with clients in cognitive-behavioral therapy for insomnia (CBT-I). Typically, sleep efficiency of 85% or higher is considered “normal,” “healthy,” “good” sleep. For example, if you are in bed for 8 hours, asleep for 7.5 of those hours, with 20 minutes to fall asleep and two episodes of waking for 5 minutes each, your sleep efficiency is 94%.

The app uses the microphone on your smart phone to measure whether you are awake or asleep based on movement. Years ago, when I worked as a student clinician at a sleep and pulmonary disorder clinic, we used actigraphy watches which then had to be downloaded, interpreted by hand, and then compared with self-report data. Amazing what smart phones can do!

I was somewhat surprised at what the app told me. Many of the nights I was sure my sleep was poor, “I didn’t sleep a wink last night,” the app indicated that, while I was awake for some of the time (feeding my baby), I was out like a light during the time I was in bed. A user-friendly graph depicted the movement associated with my sleep, and decent average sleep efficiency. I learned from a week of monitoring that I should prioritize getting to bed earlier, because when I am in bed, I’m sleeping. While I am not suffering from insomnia, the little experiment reminded me of the benefits of brief self-monitoring, and inspired me to share some information about insomnia and its treatment.

What is insomnia, anyway?

Most people have bouts of insomnia at some point in their lives, usually in response to a stressful event. These short episodes of sleeplessness usually resolve and don’t require treatment. Chronic insomnia last for months or years and can be characterized by:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up too early
  • Poor quality sleep

Consequences of insomnia include fatigue, sleepiness, difficulty with thinking (attention, concentration, memory), irritability, headaches, poor work performance, and persistent worry about sleep.

It is thought that insomnia develops as a result of three factors: predisposing factors, precipitating factors, and perpetuating factors. Predisposing factors are risk factors for developing insomnia, such as a highly sensitive biological sleep system or a tendency toward high arousal. Precipitating events are usually stressful events that result in an initial loss of sleep; for example, loss of a loved one, a stressful move, a new job, etc. Most people recover from this initial sleep loss once the stressor resolves. But the perpetuating factors play one of the biggest roles in the development and maintenance of insomnia. Some people become highly focused on their sleep difficulty, which results in heightened anxiety, maladaptive behavioral responses (going to bed early, staying in bed late, avoiding evening activities for fear that it may interfere with sleep, developing sleep rituals, or “crutches”), and unhelpful thoughts, attitudes, and beliefs about the sleep problem. Some examples of these common dysfunctional beliefs are:

“I need 8 hours of sleep to feel refreshed and function well during the day.” 

“When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.”

“When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.” 

“Medication is probably the only solution to sleeplessness.”

These beliefs tend to perpetuate insomnia by further increasing worry and arousal, focusing attention on negative consequences of lost sleep, and decreasing belief in your ability to control your sleep problem. These patterns of thinking, in addition to the well-intentioned but detrimental behavioral responses to sleep loss are the critical targets of CBT for insomnia.

How is insomnia treated with CBT?

Many people believe that medication is the only answer to chronic insomnia. However, CBT for insomnia (CBT-I) is safe, brief (usually 4-5 sessions), has lasting effects, and is well researched. CBT-I is composed of education about sleep, stimulus control strategies, sleep restriction, relaxation training, and “sleep hygiene.”

Stimulus control strategies address the issue of the bed and sleeping environment becoming associated with wakefulness, rather than sleep. In a nutshell, the recommendations go something like this:

  • Go to bed only when sleepy (not just fatigued or tired)
  • Use the bed and bedroom only for sleep (and sex)
  • If unable to sleep, get out of bed and return to bed only when sleepy
  • Wake up at the same time every day regardless of how much you slept
  • Do not nap

Simply put, implementing stimulus control strategies is not fun. Getting out of bed when not sleeping is annoying and takes work. Also, many people with insomnia have the unfounded belief that if they just stay in bed and “rest,” they will increase their likelihood of falling asleep and will at least get some R&R. In reality, more time spent in bed awake will only perpetuate the insomnia, and rest is not equal to sleep.

Occasionally, a strategy called sleep restriction is used in which the amount of time in bed is restricted to the amount of sleep a person typically needs to feel rested. This process can also be unpleasant as it results in an initial loss of additional sleep. However, after a few days, most people begin to see results.

Relaxation training can help to address the increased anxiety and arousal associated with insomnia and the process of sleep. Learning breathing and muscle relation techniques such as progressive muscle relaxation can be important targets for the management of insomnia. If bothersome thoughts and worries are a major component of insomnia (which is often the case for those who have difficulty falling asleep), taking time out of the day to focus on worries and write them down can be helpful.

Sleep hygiene recommendations are a beneficial add-on to the treatment of insomnia (but are not usually sufficient treatment) and are applicable to most “normal” sleepers. The following are some of the guidelines I’ve found to be the most powerful:

  • Wake up at the same time each day regardless of bedtime – This is part of the stimulus control instructions as well. Bedtime can be more difficult to keep consistent.
  • Avoid naps – Especially in the afternoon, naps reduce your sleep drive and may make it more difficult to get to sleep at bedtime.
  • Get regular, daily exercise – …but not right before bedtime (this can delay sleep onset).
  • Don’t watch the clock!!! – Checking the clock during a normal, middle-of the night waking can trigger many of the negative cognitions associated with insomnia and is likely to promote wakefulness.
  • Keep a quiet and comfortable sleeping space
  • Avoid going to bed hungry
  • Avoid coffee, alcohol, and nicotine – especially in the afternoon and evening.

The use of electronic devices around and up to bedtime and in bed is a problem that is becoming more and more ubiquitous and is associated with poor sleep outcomes. Using a cell phone, tablet, computer, etc so close to bedtime can be problematic for a couple of reasons, listed below:

  • Blue light exposure – Smart phones and other devices emit light that has the potential to disrupt the sleep cycle and the brain’s “understanding” that it’s time for sleep.
  • Alertness/stimulation – Engaging with your device in the bedroom environment, especially in bed, serves to associate bed and the bedroom with alertness, rather than sleep.
  • Worry – Checking email right before bedtime or in the middle of the night can initiate worry and anxious thoughts about the following day, tasks that need to be done, etc.

Remember, if you do not have a sleep problem and “problematic” sleep hygiene-related behaviors are not affecting your sleep in a negative way, don’t worry about it! But these behaviors can be important aspects to consider for those who are suffering from a long-term sleep problem.

There are good self-help resources for insomnia both online and in book form. The Centre for Clinical Interventions (CCI) has some solid information sheets, and the book Quiet Your Mind and Get to Sleep is recommended. It can sometimes be difficult to find a CBT-I provider, but there is a directory of member providers on the Society of Behavioral Sleep Foundation website: www.behavioralsleep.org.

References

Carney, C., & Manber, R. (2009). Quiet Your Mind and Get to Sleep. New Harbinger Publications.

Morin CM; Vallières A; Ivers H. Dysfunctional Beliefs and Attitudes about Sleep (DBAS): Validation of a Brief Version (DBAS-16). SLEEP 2007;30(11):1547-1554.

Spielman AJ, Caruso L, Glovinsky P. A behavioral perspective on insomnia. Psych Clin N Am 1987; 10: 541±553.

 

Condiments, the Final Frontier of Eating Disorder Recovery

By Katie Grubiak, RDN, Director of Nutrition Services

Katherine Grubiak is a Registered Dietitian with a focus on blending Western & Eastern philosophies regarding nutritional healing.

Condiments in Eating Disorder Recovery

In our work with clients with eating disorders, we help them to reintroduce recently eliminated and avoided foods that present as part of the eating disorder. We notice that as clients (both adult and child) reintroduce foods, it is often the condiments and sauces that are the last to be confronted. In some situations, clients never successfully spontaneously reintroduce these foods; we have to strongly encourage them.

“Normal” eaters enjoy ketchup on French fries, mayonnaise on a sandwich, and dressing (with oil) on salads. In fine cooking, sauces such as Hollandaise are elements that complete the dish. Watch any cooking show and you will see how integral the sauces are to the meals.

In addition to adding needed flavor and creaminess to dishes, these sauces and condiments also add the necessary dietary fat that is essential to metabolic function, hormone balance, absorption of fat soluble vitamins (Vitamins A, D, E, K), nerve coating, and ultimately brain healing.  It is said that even after weight restoration, for 6 months the body & brain are still recovering.  Gray matter, which is severely compromised in anorexia, only can be re-layered through the help of essential fatty acids. Recommendations are between 30-40% of total calories coming from dietary fat. How about we rename this macro-nutrient “essential fuels” (EFs) to honor its positive and real use in recovery?

We think it is worth pushing these condiments and sauces as one step towards a full recovery for our clients. If you are a person in recovery or a parent of a person in recovery, we hope you will consider the following suggestions:

  • Try one new condiment on a sandwich or side dish per week. This may include: ketchup, mayonnaise, mustard, aioli, etc.
  • Try dipping chips or vegetables in sauces such as Ranch dressing, salsa, or guacamole.
  • Experiment with one new creamy salad dressing (not fat free) on a salad.
  • Eat a meal that has one new sauce, such as a cream sauce on pasta, a sauce on steak, or an Asian curry.

Here are some recipes:

Chimichurri Sauce-with Argentinian roots its used as both a marinade and a sauce for grilled steak. Also try it with fish, chicken, or even pasta (like a pesto). Chimichurri also makes a great dipping sauce for french bread or a yummy spread on a sandwich! 

  • Prep Time: 8-10 minutes
  • Serves 4

Ingredients:

  • 1 cup firmly packed fresh flat-leaf parsley trimmed of stems
  • 3-4 garlic cloves
  • 2 TBSP fresh or 2 TSP dried oregano leaves
  • 1/2 cup olive oil (extra virgin cold pressed)
  • 2 TBSP red or white wine vinegar-maybe a rice vinegar
  • 1 TSP sea salt
  • 1/4 TSP ground black pepper
  • 1/4 TSP red pepper flakes (amount depending on level of heat desired)

Finely chop the parsley, fresh oregano, & garlic or place all in a food processor with just a few pushes. Place in a small bowl. Stir in the olive oil, vinegar, salt, pepper, and red pepper flakes to taste. Serve immediately or refrigerate. Perishable-so avoid keeping longer than two days.

Chili Aoli

Condiments in eating disorder recoveryUse on top of meatloaf, meatballs, or on a sandwich.

Total time: 10 minutes | Makes 1 cup.

  • 1 cup mayonnaise
  • 2 cloves garlic, peeled and minced
  • 3 1/2 tablespoons canola oil
  • 1/2 teaspoon ground cumin
  • 3/4 teaspoon lemon juice
  • 1 1/2 tablespoons dark chili powder
  • 3/4 tablespoon paprika
  • Salt and pepper

In a small bowl, whisk together all ingredients until smooth. Taste and season as desired with salt and pepper.

Trader Joe’s Wasabi Mayo can really spruce up a turkey sandwich!  

OCD and Eating Disorders – LACPA ED SIG Event – March 2016

It’s the time of year when the Los Angeles County Psychological Association SIG events are open to nonmenbers.  So, come try it out.  Details on our next event are as follows:

Thursday, March 3 at 7:30 PM

Presenter: Kimberley Quinlan, LMFT

Title: When OCD and Eating Disorders Collide: Assessment and Treatment Planning for OCD and co-existing Eating Disorders 

Description: Managing Obsessive Compulsive Disorder and a co-existing eating disorder can be quite difficult and require significant attention and prioritizing. A very important goal is to ensure that improvements in the symptomology in one disorder are not due to an increase in compulsivity in another co-existing disorder.

During this presentation, Kimberley will discuss at length how to identify and assess for Obsessive Compulsive Disorder symptoms and how to then prioritize treatment goals and tools in these cases. Participants will learn how to manage clinical time with clients, specifically when their eating disorder has become a part of their OCD compulsions.

Attendees will learn important differentiations between general OCD, OCD food-related obsessions (including Symmetry obsessions and Orthorexia) and Eating Disorder obsessions.   Attendees will learn how to prioritize treatment goals and planning (specifically targeting the use Exposure and Response Prevention and other evidence based treatment tools) when managing OCD and co-existing Eating Disorders. Attendees will also be offered a Q&A for general questions.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio:

KIMBERLEY QUINLAN is a licensed Marriage and Family Therapist in the State of California. During her training and education, Kimberley dedicated much of her research to the study of Cognitive Behavioral Therapy (CBT) for the treatment of Anxiety Disorders and Eating Disorders.

Kimberley did her internship at the OCD Center of Los Angeles and went on to become the Clinical Director of the OCD Center of Los Angeles. Kimberley currently has a private practice in Calabasas, California. Kimberley provides weekly outpatient, intensive outpatient services, in addition to 2-day Mindfulness Workshops, for those with OCD, Body Focused Repetitive Behaviors’s and other OCD spectrum disorders.

Kimberley has been featured in many world known media outlets, such as LA Times, Wall Street Journal, KCRW public radio, and the Seattle Times, discussing co-existing OCD and eating disorders. Kimberley has also consulted on various mental health issues with programs such as ABC’s 20/20 and Telemundo.

RSVP to:  drmuhlheim@gmail.com

March and April SIG meetings are open to all professionals.  During other months SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

My work in Shanghai with clients from all over the world

Eight years ago this month, I moved to Shanghai for a 2.5 year assignment.  I have been meaning to share my reflections.  Here they are:

I had been working at Los Angeles County Jail for nearly 10 years when my husband’s business plan for a site-based English Language Learning Children’s business in China got funded by the Walt Disney Company. I was by then more than a little “burned out” and ready for a change.

I know my jail co-workers questioned the legitimacy of my excuse for finally “getting out of jail.” “Really, you’re going to China?” they asked incredulously, as if I were just naming the furthest place I could think of from Los Angeles County Jail. I left my job in November 2007 and became wistful. I wondered if my kids would ever be able to remember having a working mother (they were 10, 8, and almost 6 when we left).

And so, in January 2008, my husband and I packed up our house, 3 kids and a dog, and said goodbye to our family and life in Los Angeles. We arrived in Shanghai during its coldest winter in 20 years.

Within 2 weeks of my arrival, I had coffee with a Dutch psychologist who lived in my compound and supervised the counseling program through the expatriate community center. Knowing of my expertise in eating disorders from my CV, she immediately handed me 2 cases. A friend encouraged me to apply for a job with the Singapore-based Parkway Health, which ran clinics throughout Shanghai staffed by Western-trained doctors, serving a predominantly expatriate clientele. Parkway Health promptly hired me, and within 4 months of my arrival in China I was working two jobs.

My clients were anyone who could speak English. This included clients from every continent with the exception of Antarctica (I never got to treat any penguins!). They ranged in age from children to adults in their 60s. The majority were on expatriate assignments or had children with foreign passports attending international schools. Some were Chinese who had lived abroad and were now living in China while their children attended international school. Others were American-born Chinese who had come to work in China and faced significant cultural issues. Other clients came from the UK, Germany, Brazil, Argentina, Sweden, Canada, Israel, India, South Africa, and Australia.

Map in my office in Shanghai with pins representing hometowns of patients.

Map in my office in Shanghai with pins representing hometowns of patients.

I learned that clients around the world experience very similar problems. Due to my specialty, a significant portion of my clients was seeking treatment for eating disorders. But with a short supply of therapists to treat the large and diverse population of expats in Shanghai, I also saw clients with anxiety, mood disorders, and marital problems.

I found that the stress of being an expat away from one’s family and home, and the clash of living in a foreign culture, added overlays of additional stress to whatever other disorder or issues were already there. I also found that there were a certain number of individuals who had fled their location of origin (sometimes a series of locations) in an attempt to run away from a problem; unfortunately, in these circumstances the problems had merely followed them to China.

A Cognitive Behavior Therapy (CBT) approach provided benefits for clients of diverse ethnic backgrounds. I sought additional training in Emotionally-Focused Therapy for couples and Family-Based Treatment for adolescent eating disorders to enhance my skills.

One of the most exciting aspects of living and working in Shanghai was spearheading the establishment of the Shanghai International Mental Health Association (SIMHA), an organization for therapists serving the international community of Shanghai. Over time, I proactively cultivated relationships with anyone who had been a therapist. This aided me when I needed to consult or refer to another therapist. Unfortunately, although various international schools and organizations serving expatriates retained lists of expatriate therapists, whichever list I consulted of therapists practicing in Shanghai was outdated (and the turnover was relatively rapid). Thus, I reached out to the International Mental Health Practitioners of Japan and sought their advice on forming a similar organization in Shanghai. I then banded together the various and diverse therapists I had identified in Shanghai and together we formed a professional organization of mental health professionals (also from all around the world), adopted an ethics code, and built a website and a community of therapists who could support each other. I am proud that SIMHA still thrives.

Living and working in Shanghai gave me an amazing training in cultural awareness and sensitivity. I love learning about clients’ unique backgrounds and experiencing their worldviews. I particularly enjoy working with clients of diverse backgrounds. I am sensitive to the issues of expatriation and acculturation and generational conflicts around culture. I am also comfortable and enthusiastic about engaging with people from different backgrounds, whether cultural, religious, gender orientation, sexual orientation, or lifestyle.  It is this diversity that makes the texture of life so interesting and my work so rewarding.

For Teens With Bulimia, Family Based Treatment is Recommended

Teens With Bulimia Family Based TreatmentMy original eating disorder training began in 1991 with learning Cognitive Behavioral Therapy (CBT) for bulimia nervosa (BN) under G. Terence Wilson, the co-author with Dr. Christopher G. Fairburn, of the treatment approach that preceded CBT-E. In 2010 I underwent training in Family Based Treatment (FBT) for Adolescent Anorexia Nervosa (AN) and became certified in FBT by the Training Institute for Child and Adolescent Eating Disorders.

CBT is the most effective treatment for adults with bulimia nervosa. It is an individual approach that focuses on reducing dieting and changing unhelpful thinking patterns that maintain the behavior. FBT is the most successful treatment for adolescents with AN. FBT encourages parental control and management of eating disorder behaviors, but does not address distorted thinking regarding shape and weight. Over the last five years, there has been no clear guideline on which treatment I should offer to adolescents with BN.

This changed in September 2015 with the online publication of “Randomized Clinical Trial of Family-Based Treatment and Cognitive-Behavioral Therapy for Adolescent Bulimia Nervosa” by Daniel Le Grange, Ph.D., James Lock, M.D., W. Stewart Agras, M.D., Susan Bryson, M.A., M.S., and Booil Jo, Ph.D. which has been published in the November Journal of the American Academy of Child and Adolescent Psychiatry.

In this study, researchers at the University of Chicago and Stanford randomly assigned 130 teens between the ages of 12 and 18 years old with BN to receive either CBT-A (CBT adapted for adolescents) or FBT-BN (FBT for adolescent bulimia). The teens received 18 outpatient sessions over the course of six months. Assessments were conducted at end of treatment and at six and twelve month follow-ups. After the completion of the treatment, bulimia abstinence rates were 39% for FBT patients and 20% for CBT patients. By the six-month follow up, these rates rose to 44% for FBT patients and 25% for CBT patients. These differences were statistically significant. By 12 month follow up, while the bulimia abstinence rate continued to rise for both populations, the difference was no longer statistically significant.

The researchers concluded,

FBT-BN is likely a better initial treatment option compared to CBT-A for those adolescents with clinically significant bulimia behaviors. FBT-BN leads to quicker and higher sustained abstinence rates that are maintained up to 12 months posttreatment…It appears that, similar to their adolescent peers with AN, adolescents with BN can benefit from an approach that actively involves their families in the treatment process. However, given that there were no statistical differences between these 2 treatments at 12 months post-treatment, CBT-A remains a viable alternative treatment for this patient population, especially for those families who would prefer a largely individual treatment or when there is no family available to be of help.

In interviews about the study, Dr. Le Grange said, “Parents need to be actively involved in the treatment of kids and teens with eating disorders.”

This study reinforces my experience. Although I have employed CBT for bulimia in working with adolescents, rarely do adolescents fully embrace the work required on their part for CBT to be successful. I have found it more effective to use FBT with their family and to supplement with some individual CBT if the adolescent appears ready and motivated for additional independent work. Bingeing and purging are serious symptoms carrying the risk of heart and esophageal problems and death. Thus administering a treatment that brings a faster rate of remission of symptoms is a priority.