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LENSES
That bring eating disorder treatment into focus.

Friday, March 13, 2009

No Laughing Matter

Terry Schiavo
Ice Tea
Bulimia
Medical Negligence
1 Million Dollars


Major Diagnoses

BED - Binge Eating Disorder

AN - Anorexia Nervosa

BN - Bulimia Nervosa


BED - Depression, anxiety, adjustment disorder,
dependency issues.

AN - Obsessive Compulsive Disorder. Family
frustrations and fears, physician’s referral due to
weight loss. Client feels nothing is wrong.

BN - Personality disorder, extreme depression.
Referral from therapist colleague, self-referral. “I
believe you are the only person who can help me!”


ASSESS

Anorexia Nervosa: Differential Diagnosis &
Workup http://emedicine.medscape.com/
article/286063-overview (in handout)

Michigan Eating Disorder Screening
Instrument (MEDSI)


FOUR AREAS OF INTERVENTION

Eating and exercising behaviors.

Body image.

Emotions.

Relationships.


LENSES give:
clarity & focus


Binge Eating Disorder

ABANDONMENT

Pleasant & compliant.

Distorted Body Image

Use Eating as Source of
Comfort & Distraction


Diagnosis - Depression, anxiety, dependency issues & weight issues bring the
client to treatment.

Referral

Nutritionist

Overeaters Anonymous (12 Step group for compulsive eating)

Group therapy addressing BED.

Medications from Primary Care Physician or Psychiatrist

Exercise Classes for Large Bodied People


BED Treatment through the lens of
ABANDONMENT

Weight History to identify pertinent themes.

Teach methods of postponing a binge and becoming more aware of feelings.

Encourage engaging in activities of interest that one is putting off until thinner.

Cognitive Behavioral Therapy to challenge distortions.

Trauma therapy.

Process the client’s efforts to be compliant and agreeable with the therapist.

Teach emotional awareness, acceptance, containment and communication.

Give permission to client to experience and express anger.


ABANDONMENT

Cognitive Behavioral Therapy to challenge distortions.

Trauma therapy for dissociative symptoms.

Solution Focused Therapy.

Process the client’s efforts to be compliant and agreeable with the therapist.

Challenge compliance gently as a wish to maintain what the client experiences as a
fragile connection.

Teach emotional awareness, acceptance, containment and communication.

Create a predictable safe therapeutic environment while encouraging client to
differentiate, express anger and declare expectations.


ABANDONMENT

Teach the use of mirror work to recognize and accept body as it is not as client
imagines it is.

Encourage involvement in exercise.

Encourage forms of bodywork with appropriate practitioners such as massage and
yoga.

Teach the use of the hunger scale.

Teach methods of limiting food, such as choosing small portions of three types of
food and eating them slowly then choosing more.

Doing a food history with foods a person feels is an inevitable binge food.


Anorexia

CONTROL

Severe Restricting or Cessation of
Eating

In Therapy Against Their Will

Terriﬁed of Eating and of Gaining
Weight

Distortion Believing They Are Fat
Despite Emaciation


ANOREXIA

Diagnosis - client usually comes with suspicion of diagnosis from referring source.

Assemble treatment team.

Nutritionist, IMMEDIATELY!!!!!

Psychiatrist & Primary Care, SOON!

Evaluate for immediate hospitalization in eating disorder unit.

Eating disorder group, if one is available.

Continue evaluating need for hospitalization throughout treatment.


AN Treatment through a lens of
CONTROL

Establish rapport using Motivational Interviewing strategies.

Explain relationship between restricting and an effort on client’s part to establish
control over something.

Wonder about what she feels out of control of together.

Weight History to begin the detective work of understanding.

Establish and maintain an aura of acceptance of the symptoms and recognition
that others are freaking out about her eating.


AN Treatment - Continued

NEVER pressure her to eat.

Assist her in understanding why others are frightened for her.

Invite family members in for family therapy and extract their commitment to not
pressure her in her presence.

Conduct ongoing family therapy to assist the family in learning appropriate
communication strategies and boundaries.


AN Treatment - continued

Needs - help the client to realize it is acceptable to have needs.

Needs - help the client to sort out how to get some of their needs met.

Fear of Being Fat - This fear exists at delusional proportions.

Discuss meanings client has attached to body size.

Explain that angst about life has gotten displaced onto body size.

Cognitively challenge this as a distortion and teach client to do the same.


AN Treatment - continued
MOST IMPORTANT

DON’T PANIC!!!!

Working with anorexics is frightening.

The therapist will feel overwhelmed and experience extreme helplessness.

Reach out to knowledgeable colleagues.

Persevere. As you learn to contain your helplessness and hopelessness and
proceed your client will learn to do the same and you will be on your way to
recovery.


The devestation of eating disorders.

http://www.youtube.com/watch?v=I6e98OlDclU


Bulimia

TRUST

Bingeing & Purging

Inconsistent

Unreliable

Risk of Premature End to Therapy

Loathing of Body, Emotions and
Need for Closeness


BULIMIA
Diagnosis - Client will come from other therapists and have seen many therapists.
Client will present as personality disordered, borderline, histrionic or even bipolar.

Referral

Nutritionist.

Medication consult with psychiatrist.

Primary care physician.

Couples therapist.

Possible need for referral to inpatient trauma unit.


BN Treatment through a lens of
TRUST

Establish rapport. Remember this person has extreme issues with trust. Do an
extended and careful history of all previous treatments and predict that the client
will have a strong impulse to prematurely terminate this treatment.

Obtain client’s promise to discuss this impulse with you before acting on it.

Explain and educate that bulimia develops when certain individuals are subjected
to extremely untrustworthy people or environments.

Pay careful attention to issues of timing, phone calls, and other contact.

Development of trust is built on therapist acting in predictable ways.


BN Treatment continued

Prescribe not bingeing, with permission to binge.

Prescribe not purging, with permission to purge.

Refer to nutritionist and maintain regular contact with the nutritionist to discuss
client progress and compare notes.

Develop an understanding that bingeing and purging are symbolic for how
difﬁcult it is for client to take good things in and keep them.



Recognize client’s loathing of her body.

Recognize client’s suspicion about caring.

Weight History to understand weight ﬂuctuations and changes in eating behaviors
along with stresses and betrayals in life.

Encourage physical self care: appropriate exercise, massage, use of lotions, and
safe, nonsexual touch.



Teach emotions 101. Dialectical Behavior Therapy is helpful. Clients have been
traumatized by emotions of others and are often fearful of their own emotional
experience.

Trust is the belief in another person’s integrity.

Help client hope that as they integrate they will choose more trustworthy people
to relate with.

Conduct limited family sessions for the purpose of education about the eating
disorder and refer to colleague for more extensive work.


A
C
T


Abandonment
Control
Trust


Anorexia Nervosa
Bulimia Nervosa


Eating Disorders Cause Suffering and Death
You Can Help
Please Do!


Tish Vincent, MSW, LMSW, ACSW, CAAC
790 W. Lake Lansing Rd., Ste. 300
East Lansing, MI 48823
517.332.2433 (phone)
517.332.4311 (fax)
TVinc1988@gmail.com


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