On Empowering Parents—Not Pathologizing Them

Empowering Parents I often write about the importance of including parents in the treatment of adolescents and young adults. My work is informed by my training in Family-based Treatment (FBT), which as a central part of treatment seeks to empower parents to help their ailing children with eating disorders to return to health. When asked why families should be the center of treatment, I usually cite the AED guidelines on the role of the family, The Nine Truths About Eating Disorders, and the vast evidence base underlying FBT. I often discuss how providers who see families with children with eating disorders get a distorted view of the family: they do not have the benefit of having seen how it functioned prior to the eating disorder. Parents’ behaviors are often pathologized when they are actually the normal response of healthy parents to a child in distress.

This post is different—here I will share a more personal perspective.

Recently, one of my children (anonymized here because the story is theirs to tell) stumbled. My child was fighting a mental health issue that was not an eating disorder. The experience of watching my child struggle, and struggling to help my child, has further informed my thinking on this issue.

Sadly, it remains common for parents of children, adolescents, and young adults with mental health problems to be judged, labeled, blamed, and excised from the child’s treatment. This has happened to families with whom I have worked. Parents have sometimes been labeled as “enmeshed” or “overprotective.” This is not productive.

I’m writing this blog to share how beneficial it was personally to be included in my young adult child’s treatment. First, let me give you some background.

For Most of My Parenting Years, I Was Balanced

I care for my children deeply and have chosen a career that has allowed me the flexibility to be present in their lives and to be their primary caretaker. At the same time, I have been anything but a coddler. All three of my children were sleep-trained at less than six months, left at a young age with non-family babysitters, and dropped at preschool on the first day. I shed some tears, but I was not a parent who stayed and watched outside of the classroom for months; I went to work.

I also developed a certain toughness to set limits. During my kids’ early years, I worked at Los Angeles County Jail, where I encountered numerous inmates demanding sleeping medications or “more desirable” housing assignments and then threatening suicide when they didn’t get their way. I became a pro at placing inmates on suicide watch and walking away despite their sometimes yelling at the top of their lungs that they would tell the entire jail, “It’s because of you, Dr. Muhlheim, that I will kill myself.”

I am not a perfect mother, but I am a highly dedicated, devoted one. I have sought to balance my joy in raising my children with time to pursue my own interests and career.

When My Child Started to Struggle I Became Highly Involved

When I work with parents of teens and young adults with eating disorders, I encourage parents to trust their instincts. “Parents know their kids best,” I tell them. During the transition to college, when my child was supposed to be individuating, I knew something was amiss, so I hovered more than usual.

Fortunately, when my child wobbled, I was prepared. I trusted my instincts. I was fully present: watching, standing close, getting my child help. I helped save my child’s life. There are powerful cultural expectations that parents should back off and allow their child to individuate. There is less support for parents who choose to step in at this moment. Observing my behavior at that time, I may have been labeled as overprotective.

Even my child, who recognized the need for parental help, was fighting against it. This was confusing to their therapist, who later wrote in a report, “There is a weird dichotomy between the child and the parents. The child refuses to sign a release of information for the therapist to speak to the parents, but the child appears to reach out to the mother for support.”

Rather than pathologizing hovering parents, we need to recognize that they are doing it for a reason.

Professionals Supporting, Not Blaming Parents

The hardest moments of this whole journey were those times that, on top of his worry for our child and whether they could or would actually recover, my husband blamed himself for causing the problems our child was facing. This tendency of parents—to blame themselves for any problem that befalls a child—is typical, whether or not the problem could be attributed to parenting. I noticed that when my husband started to blame himself, we both became hopeless and lost focus on helping our child. These were dark times—it was hard to have our own faith and be present for our child.

Fortunately, we had the means to seek out high-quality treatment. Our child was treated in a center that specializes in treatment often used for a problem for which parents have historically been blamed. In this program, we as parents were given much-needed support and services as well. Importantly, the clinicians never indicated they believed that we had caused our child’s problems. Instead, we were validated, supported, and given a framework for understanding our child’s problems that did not point the finger at us.

Made/Makes All the Difference

Further, our responses to our struggling child were validated as a reasonable response to experiencing our child’s struggles. We were supported in our child’s recovery, empowered to play a role, included in the treatment, and seen as parents doing our best. This was profound. I think it made all the difference.

Our child worked hard and so did we. With the proper help and our support, our child is now healthy and firmly back on track. My hope for other parents of floundering adolescents and young adults is that they are treated with the same respect that we were.

November 2016 LACPA Eating Disorder SIG events

The Los Angeles County Psychological Association Eating Disorders SIG will be hosting 2 events in November 2016

Tuesday, November 1 – 7 – 8:30 pm in LACPA Office (Encino) – DBT for Eating Disorders 

Speaker: Charlotte Thomas, LCSW, Program Manager of Portland DBT’s Pathways to Mindful Eating Program

Talk Description: charlotte

Dialectical Behavior Therapy (DBT) is an evidence based treatment developed by Marsha M. Linehan, PhD for complex multi-diagnostic individuals with pervasive emotion dysregulation and high risk suicidal behavior. Over the past two and a half decades, research has consistently demonstrated DBT as being effective for patients with a variety of complex problems such eating disorders and substance abuse disorders, where emotion dyscontrol is at the core of the patient’s issues and often interfere with treatment and long-term maintenance of therapeutic progress. This presentation will use a session- to-session birds eye view of the implementation of DBT with complex eating disorders in order to demonstrate use of DBT principles and skills in a concrete, “real world” manner. My hope is to communicate my excitement for DBT, share outcomes commonly generated by DBT, and to generate curiosity among individuals participating in the training.

Goals:

Upon completion of this presentation, participants will:

  • Learn about the first 7 sessions of treatment using a composite client with a complex Eating Disorder
  • Understand the biosocial model of DBT as applied to a composite client
  • Learn about the timing and use of strategies such as dialectics, behavioral chain analysis, and diary cards

Speaker bio:

Charlotte Thomas, LCSW

Charlotte received her master’s degree in Social Science Administration (MSSA) at Case Western Reserve University in Cleveland, OH and trained with Lucene Wisniewski PhD, FAED and Mark Warren MD, FAED for the following 4 years in the evidence based treatment of eating disorders. She is now a licensed clinical social worker in the state of Oregon. Charlotte’s professional interest is in treating eating disorders and associated needs including borderline personality disorder, depression and anxiety. She has experience in private practice mental health settings, providing individual, family, and group services for teens and adults. At Portland DBT Institute, Charlotte is the Program Manager for the Pathways to Mindful Eating program and provides direct service to clients, supervision to staff, and serves on the management board for the clinic helping to inform general clinic policy.

 Friday, November 4 – 12 to 1:30 pm in LACPA Office (Encino) in conjunction with the Couples SIG – Panel Discussion: The Impact of Particular Addictive/Compulsive Behaviors on a Couple’s Relationship, and How to Help – Hoarding, Gambling, and Eating Disorders

3 speakers include:

  1. Regina F. Lark, PhD: Family Stuff
  2. Cristin Runfola, PhD:  Uniting Couples in the Treatment of Eating Disorders.
  3. Margaret Altschul, MBA, MA, LMFT: Win, Lose or Draw:  What happens to couples when one partner is a problem gambler?

Speaker bios and talk descriptions below:

Regina F. Lark, PhD: Family Stuff: The impact of compulsive hoarding on relationships with family and friends, creates as much dysfunction as the “stuff” piled around the room. Dealing with it effectively “takes a village” and a strategic plan to calm the relationships between loved ones and the physical environment. Dr. Lark’s presentation will explore the effects of the hoarding disorder and chronic disorganization on the family dynamic, and present strategies for finding clarity amidst the chaos.

Dr. Lark is the owner of A Clear Path: Professional Organizing and Productivity. As a Certified Professional Organizer she specializes in working with people with chronic disorganization, ADHD, and hoarding. She is also a relocation specialist, helping families move or downsize from one home to the next. She is a featured speaker and educator, and is the author Psychic Debris, Crowded Closets: The Relationship between the Stuff in your Head and What’s Under your Bed, Second Edition, (Purple Books, 2014). She serves on the Board of the National Association of Professional Organizers, and is a member of the National Speakers’ Association. She earned a  Ph.D. in History at the University of Southern California.

Cristin Runfola, PhD: Uniting Couples in the Treatment of Eating Disorders. Dr. Runfola will describe recently developed couple-based interventions for eating disorders, including how core cognitive-behavioral couple therapy interventions can be applied and integrated with individual CBT principles for these disorders. Further, she will present data from recent pilot studies conducted with couples affected by anorexia nervosa (UCAN) or binge-eating disorder (UNITE), which yield promising results.

Cristin Runfola, PhD, is a clinical instructor at Stanford University who specializes in the treatment and research of eating disorders. Dr. Runfola’s primary research interest is in developing and testing the efficacy of clinical interventions designed to improve outcome for eating disorders. She underwent extensive training in cognitive-behavioral couples therapy and worked with colleagues at UNC-CH to develop and test manualized protocols for treating anorexia nervosa and binge-eating disorder in a couple context. She is the recipient of various awards, such as the AED Clinician Scholarship Award and NIMH/AED Early Career Investigator Travel Fellowship Award, for her work.

Margaret Altschul, MBA, MA, LMFT: Win, Lose or Draw: What happens to couples when one partner is a problem gambler?

Imagine discovering that your joint bank accounts are gone, your credit cards are charged to the max, and your car is about to be repossessed. This is often the scenario confronting couples when one person is a problem gambler. Problem gambling by one partner brings to a relationship all of the chaos, fear and betrayal of addictions and affairs combined. This presentation will help you gain awareness and understanding about Problem Gambling and learn how you can help couples dealing with the unique challenges this addiction creates.

Margaret Altschul, MBA, MA, is a Licensed Marriage and Family Therapist with a background in education and business. In addition to working with couples, Ms. Altschul applies her training and experience in using EFT and Gottman methods to help adults improve difficult relationships with parents, siblings and people at work. Margaret is authorized by the CA Office of Problem Gambling to provide counseling (at no cost to the client) to people with gambling addiction as well as family members affected by gambling.  She is Director of the Wagner Program at American Jewish University where she trains human services volunteers in basic counseling skills

* LOCATION for both events: LACPA ADDRESS and PARKING INSTRUCTIONS: 6345 Balboa Blvd, Bldg 2, Suite 126, Encino 91316. The buildings are on the south-west corner of Victory and Balboa, and Bldg 2 is the second building from Balboa. If you come from the Westside, take the 405 to the 101 and exit going north on Balboa to just before Victory (park on the street or in the Sepulveda Basin Sports Complex (6201 Balboa Blvd.) on the west side of Balboa, just south of Victory).  Or take the 405 to Victory (past the 101 if you are coming from the Westside) and exit West onto Victory.  Take it to Balboa and turn left, now heading south. On your right, you will see the buildings. Go a bit past the parking lot for the building (we are not allowed to park there during the day), past the Army’s center to the next driveway, which is for the Sepulveda Basin Sports Complex (2nd driveway past the Busway), and park in there. Or park on the street just south of the entrance for the sports complex parking lot. Both sides of Balboa have all day free parking. Allow a 3 – 5 minute walk to the buildings. Walk into the building’s parking area and go to the second building. The LACPA office is right by the entrance off the parking lot, on the left if you walk in from the parking area. Wherever you park, please check the signs

Parking at The Encino Office Park lot between the hours of 9am – 6:30 pm is restricted to building tenants only. We can park there in the evening and on weekends, but not 9 – 6:30 weekdays.

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 

DBT Skills for Eating Disorders

DBT Skills for Eating Disordersby Elisha Carcieri, Ph.D.

Both cognitive behavioral therapy for eating disorders CBT-E, and interpersonal therapy (IPT) are effective treatments for bulimia nervosa, binge eating disorder, and patterns of disordered eating that don’t meet criteria for diagnosis. CBT for eating disorders involves making changes to patterns of behavior and thinking that serve to maintain the vicious cycle of eating disorders. Most people who undergo these therapies get better in response to treatment and continue to improve after treatment has ended. However, for some clients, the emotional and mood regulatory components of binge eating and/or purging represent a significant part of what keeps their eating disorder going.

According to the affect regulation theory of eating disorders, negative emotions such as anxiety, sadness, and anger precede episodes of binge eating, and individuals engage in binge eating in order to distract from or reduce negative affect or aversive emotions. Behaviors such as laxative use and vomiting may be used to ease anxiety about weight gain as a consequence to overeating. Clients often describe having a difficult time identifying, expressing, and tolerating emotions (especially negative emotions), and the disordered eating behaviors are described as providing some relief, numbing, or outlet. The binge eating and/or purging provide a temporary escape from negative emotions. Unfortunately, the vicious eating disorder cycle continues, as the escape is brief and usually followed by feelings of failure, guilt, and shame.

Dialectical behavioral therapy (DBT) was developed by Marsha Linehan for the treatment of borderline personality disorder, a mental health disorder characterized by emotion dysregulation and risk for self-harm and suicidal behaviors. DBT is influenced and incorporates both cognitive behavioral strategies and mindfulness/zen-based strategies. Inherent to DBT is the notion of practicing both acceptance of the client and their current behaviors and circumstances, and confidence in the client’s ability to make change through the use of adaptive skills.

In its standard form, DBT is delivered with multiple components: individual therapy, group skills training, telephone coaching, and a weekly consultation group for the therapists to provide support and ensure quality delivery of the therapy. DBT skills include mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. DBT also focuses on behavior through the use of “chain analysis,” which involves reviewing problem behaviors (binging and purging), prompting events, vulnerability factors, and actions, thoughts, or feelings that eventually led to the problem behavior. Clients also identify skillful solutions to the problem behavior, consequences of the behavior, as well as plans to reduce the behavior in the future. The flexibility in thinking that is characteristic of DBT acts in appropriate opposition to the patterns of black and white, or all-or-nothing, thinking that is so common among clients with eating disorders.

There is an adapted form of DBT developed specifically for the treatment of eating disorders that combines the individual therapy and skills training components. DBT skills in and of themselves can also be taught and incorporated into other treatment plans. DBT skills provide valuable lessons, not only for eating disorder sufferers, but also for anyone looking to improve their quality of life.

The following are the DBT skills relevant to the treatment of eating disorders:

Mindfulness – The skills of mindfulness are essential to DBT. These skills foster focusing one’s attention and mind in the present moment, without judgment and acknowledging that the moment is fluid and ever-changing. Bringing awareness to what is going on within our bodies and minds as well as outside of ourselves. Binge eating is considered a mindless behavior that is improved with an increase in awareness of thoughts, emotions, and bodily sensations that occur before, during, and after eating, binging, and/or purging, or while having the urge to do so.

  • Example: Mindful eating – Clients are guided through the process of slowly and deliberately eating a raisin while observing, describing and participating fully in the experience. This practice is encouraged during meal times as eating mindfully acts in opposition to the loss of control and mindlessness that is characteristic of binge eating.

Emotion Regulation – Enhancing control of emotions through identifying and naming emotions, reducing and managing negative emotions, accepting and increasing resilience to extreme negative emotions, and increasing positive emotional experiences. These skills encourage the use of coping strategies other than binge eating.

  • Example: Loving your emotion – Based on the principle that mindfulness encourages accepting the entire range of emotions and that one can reduce suffering by avoiding resistance of emotions. During guided meditation clients practice bringing awareness to their emotional experience with radical acceptance, no matter what their emotional experience may be in the moment. Acceptance and love of all emotional experiences eventually reduces the tendency to escape or regulate these emotional experiences through binging or purging.

Distress Tolerance – Sometimes situations or circumstances cannot be changed. Distress tolerance involves learning to tolerate negative emotions or crisis situations without responding in unhelpful ways, such as binging or purging.

  • Example: Half Smiling – Based on experimental evidence showing that our facial expressions communicate with our brains and have an effect on our inner experience, this skill teaches facilitating inner acceptance by adopting a facial expression consistent with acceptance, the half-smile.

DBT skills are best learned with the guidance of an experienced therapist. They take commitment and practice, but the benefits are far-reaching. If you are suffering from an eating disorder, don’t hesitate to seek help. There are effective therapies out there!

References

Linehan, M. M. (2014). DBT® skills training manual. Guilford Publications.

Polivy, J., & Herman, C. P. (1993). Etiology of binge eating: Psychological mechanisms.

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