Living With Food: The Science Supporting Eating Disorder Treatment

By, Samantha Mishne, LISW-S, LICDC

How do you move from a willful place to a willing place? I remind myself willingness is not a thing or a place; it is instead a view on life. Life is happening all around and I can either be willing to accept the change or feedback I receive, or I can be willful and in turn stay miserable, or say "yes, but". I think about this often with the clients I sit with who are asked or sometimes forced to make changes that are often times reinforced by the world we live in. The strength that they exhibit to move to a willing place is inspiring. I say to the young people who participate in family based treatment, your parents are going to reefed you, so you can either stay willful or move to a willing place. The nourishment that food provides often increased people’s ability to a move to a willing place along with parents resolve to care for their children.

When trying to increase willingness the first thing I do is really try and listen to what it is that someone thinks or wants me to do, then I pro and con making the changes vs. staying the same. Ultimately what moves me to a willingness place is being witness to the change my clients make daily and my acceptance that change is constant. Though I say often that I do not like change the older I get the more I am realizing it is constant. You can only push a way for so long before you need to be willing. It is important to note that there are no shades of gray when it comes to willingness. Currently I am pushing away the water stain on my ceiling because I know I have a leak which I need to become willing to have someone come out and fix. Yes this is not as big an issue (no pun intended) as gaining weight, increasing meal plan compliance, not exercising . . .but it is an example of how every day we are faced with a
choice to be willing or willful and we must accept the consequences. I will let you know if my ceiling falls in because I have yet to move to a willing place.

Should you have any questions or comments regarding this post please email blog@eatingdisorderscleveland.org.

Last week, the Cleveland Center for Eating Disorders visited Normandy High School in Parma to educate students on the dangers of eating disorders and the importance of early detection and treatment. Family and Consumer Sciences teacher Donna Rowan invited two clinicians from our center to talk to her students in her Healthy Foods class. 

Her students had just completed a study on eating disorders, so it was a great opportunity for us to discuss real-life situations and issues surrounding this devastating illness.

Board certified Karen Kristy, APRN, and Joanna Hardis, LISW, spoke about the diagnosis and assessment process, life cycles of the illness and comprehensive eating disorder treatment programs. In addition, they debunked common myths about eating disorders.

Karen and Joanna work in our adult and adolescent assessment area at CCED and explained to students what potential patients may experience. Patients receive a thorough evaluation and may be asked about his/her eating habits, beliefs and behaviors. We also recommend that patients are assessed by a medical physician, which may include laboratory testing and an EKG. Finally, our interdisciplinary team will discuss the individual’s treatment needs.

The clinicians also talked about the multiple levels of treatment programs available, from outpatient programs like the ones CCED provides to inpatient residential care. They touched on advancements in the treatment field, informing students about evidence-based care, such as Dialectical Behavioral Therapy and Maudsley Family Based Therapy, which have been shown to offer patients a greater chance for recovery.

After the discussion, Karen and Joanna opened it up for a question-and-answer session.

“The students took away the message that eating disorders can happen to anyone and they are extremely dangerous,” boasts Donna. “I feel the students better understood the serious [nature] of this issue because the ladies explained they have clients from all over the Cleveland area, including fellow Normandy Invaders!”

It was a great experience for everyone involved. In fact, so much so that Donna invited Karen and Joanna to return next semester, and they agreed!

If you’re interested in CCED clinicians speaking to your students or organization about eating disorders and treatment programs, please contact Katie Dent. She can be reached at 216.765.0500 or kdent@eatingdisorderscleveland.org.

By Drs Lucene Wisniewski and Mark Warren

Over the last 15 years Dialectical Behavioral Therapy (DBT)  has gone from being virtually unknown to being a term utilized by many treatment programs. DBT is an evidence based therapy, initially designed for Borderline Personality Disorder, and more lately for other diagnoses including eating disorders (Wisniewski, L., Safer, D., & Chen, E.Y., 2007). With its increase in popularity among treatment providers it is important to be clear about what it means to “do DBT” so an individual knows if they’re receiving evidence based care.

Comprehensive DBT treatment, initially described by Marsha Linehan, has four components: Individual therapy, skills group, 7 day week phone consultation availability, and consultation team for therapists known as “therapy for therapists”. Unless all four of these components are present, a program is not providing comprehensive DBT treatment.  Additionally, in order for a therapist to be capable of providing DBT, a significant training process is generally required. This training process necessitates a therapist taking a non-judgmental stance, the ability to encourage motivation and commitment with their client, extensive knowledge and understanding of the DBT skills and therapeutic techniques, and the balance of accepting where a client is while moving them towards change.

For these reasons, as well as other reasons related to the complexity of providing any new therapy, comprehensive DBT programs are in fact very difficult to create and to maintain. If you are evaluating a treatment program and they say that they “do DBT” it is important that you find out exactly what this means. In many instances programs use the term “DBT” as short hand for skills groups based on DBT skills. Other programs or therapists may have had DBT training are are attempting to use the stance of the DBT therapist but may not have many of the components necessary to meet the rigorous criteria for fully providing comprehensive DBT. The interested consumer should be aware that there is some data suggesting that DBT skills alone may be adequate for people suffering from Binge Eating Disorder or Bulimia Nervosa who have very few symptoms (for example, binge eating 2 times per week or less). There is no data to suggest that skills alone are helpful for clients with anorexia or those with higher frequency bingeing and/or purging behavior, or for those eating disorder patients who also suffer from co-morbid disorders such as depression or PTSD.  So while programs may be strengthened by the inclusion of some DBT components, the current expert option suggests that patients with complex eating disorders will benefit from comprehensive DBT treatment.

Wisniewski, L., Safer, D., & Chen, E.Y. (2007) Dialectical Behavior Therapy for Eating Disorders. In L.A. Dimeff & K. Koerner (Eds.), Dialectical Behavior Therapy in Clinical Practice (pp. 174-221). New York, NY.

Should you have questions or comments regarding this post please email blog@eatingdisorderscleveland.org

Contributions by Sarah Emerman

We are excited to tell you about a current publication by CCED’s Drs Anita Federici and Lucene Wisniewski in A Collaborative Approach to Eating Disorders edited by June Alexander and Janet Treasure. The article, titled "Integrating dialectical behavioral therapy and family-based treatment for multidiagnostic adolescent patients", gives a brief overview of Dialectical Behavioral Therapy and Family Based Therapy, along with a rational on why an integration of these two treatment modalities may be beneficial for multi-diagnostic adolescents. The article suggests that a collaboration between FBT and DBT therapies will help historically difficult to treat adolescents manage self-injurious behaviors (eating disorder and otherwise) by focusing largely on emotion regulation in the midst of participating in an FBT model. Furthermore, a focus on radical acceptance of the current treatment plan and a balance between change and validation serve to help the adolescent and their family decrease blame and increase a non-judgmental stance throughout the recovery process. Research is currently being conducted at CCED on the effectiveness of the integration of these two models.

For more information please read Federici, A. & Wisniewski, L. (2012). Integrating dialectical behavioral therapy and family-based treatment for multidiagnostic adolescent patients. In Alexander, J. & Treasure, J. (Eds.), A collaborative approach to eating disorders (177-188). New York: Routledge.

Should you have any questions or comments regarding this post please email blog@eatingdisoderscleveland.org.

By, Dr. Mark Warren

A central tenant of Dialectical Behavioral Therapy (“DBT”) is a goal is work towards having a life worth living. When we apply DBT to eating disorder treatment we take a strong position that re-feeding and the decrease or cessation of behaviors has to occur before we can focus our attention to our long-term goals. Because eating disorders may make us feel miserable and unhappy with ourselves, our lives, and our bodies, it is easy to hope that after behaviors are gone and re-feeding is complete, that a lot of this misery will cease. Certainly we hope for the greatest reduction in unhappiness that is possible, but stopping behaviors does not mean in and of itself that pain and misery will end. As you move through the stages of treatment and become medically and behaviorally stable, your therapist will begin to help you work on building a life outside of treatment that you feel is satisfying. Building a life worth living involves feeling accomplished, effective, competent, and on a path to a life that will be satisfying to you. It’s a life in which you get up in the morning and the activities of that life lead you in a direction that will give you the satisfaction and goals you desire. As eating disorder behaviors decrease, its imperative to add activities, people, and goals back into the space that the eating disorder used to fill. Achieving happiness is an elusive goal, worth pursuing in many ways throughout our lives. A life worth living encompasses happiness, but can be a more straightforward goal where we truly understand what we want to accomplish in our lives and set ourselves on a path to try to reach those goals.

For more information on Dialectical Behavioral Therapy check out the following link:

http://www.behavioraltech.com/downloads/dbtFaq_Cons.pdf

Should you have questions or comments regarding this post, please email blog@eatingdisorderscleveland.org.

Contributions by Dr. Lucene Wisniewski and Sarah Emerman

The term “evidence-based treatment” refers to therapy that has demonstrated statistically significant improvements or changes in behavior. In most kinds of healthcare, the only kind of treatment a person would accept is something that is evidence based. If someone was getting treatment for cancer, diabetes, or another life threatening illness, they would seek out care that had significant evidence that it worked. Unfortunately, the history of psychiatric treatment is filled with ineffective care used because it was marketed well or because there was nothing else available. Luckily this is no longer true.

Evidence-based therapy for the treatment of eating disorders has only existed for the past 15 years. Although various types of therapy have been proven to show progress in some clients, evidence to support any given treatment is not as good as we would like it to be. It is, however, better than it used to be. The major limitations to research are the short length of many trials in what we now know are long term illnesses, and the difficulty of doing randomized controlled clinical trials. Nonetheless, given that there was no effective treatment prior to 15 years ago, what we know now is a significant improvement.

For adults, evidence-based treatments include Cognitive-behavioral therapy, Dialectical-behavioral therapy,and Interpersonal therapy. If you are 18 years or older and are currently suffering from an eating disorder, these are the therapies to try first. If you are under the age of 18 and have anorexia, the Maudsley method is the only treatment that is evidence-based and should therefore be tried prior to any other treatment. We will cover each of these treatments separately over the next few weeks.

Next week: How can I tell if my therapy is working?

Contributions by Sarah Emerman