 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Today's presentation is probably going to be a little bit shorter than the other ones have been, depending on how much we converse throughout. There are several places during this presentation where I'm going to elicit feedback from you, elicit responses. So just kind of tune in for those a little bit. I tend to like it better when there's more interaction, whether I'm a participant or an instructor. So we're just going to see how that goes. I know there's a little bit of a lag for some of you, just depending on how far away you are from Nashville, but hopefully it won't be too bad. In response to the question that I got at the end of the last presentation, I did look up the statistics for relapse. And they're about the same as relapse rates for most everything else. Unfortunately, especially addictions and those sorts of things. You're looking at anywhere from 35 to 60% relapse rates. And some of the things that impact relapse are what age the person became symptomatic, current stressors in that person's life because they can set in motion the stuff for a relapse. And those are the two biggest things that they found. And the severity of the disorder when the person sought treatment has also been correlated with relapse rates. If it was something that was super ingrained that they'd been doing since they were 10 or 11, it's going to be harder to maintain recovery. Now, most of the studies that I looked at really didn't effectively define relapse in terms of, you know, are we talking for somebody who's an anorexic who had regained to an adequate weight, what level did they need to lose to in order to be considered relapsed or just losing weight period and getting back into that mindset was that considered a relapse. Same thing with bulimia. You know, when we look at if somebody has a resurgence of purging behaviors, if they're just purging, I say just, but if they go from purging six times a day or something to purging, you know, once a week or once or twice in discrete episodes, is that a relapse or is that what we call in addictions literature a slip. So, you know, I wish I could say that we really knew. And there's also a lot of shame that goes along with relapse regardless of whether it's addiction or eating disorders. And even to some extent anxiety and depression, because sometimes people feel like they should have an under control. And then all of a sudden by the bank, they're having another episode. And so when patients come back, I encourage them to use mindfulness strategies regardless of their diagnosis. And if they start to notice that some of those old behaviors or ways of thinking start to reemerge, you know, maybe it's time for a tune up session. Now that can be with me that can be a support group. It doesn't the person can decide what they need. But if they're mindful of what's going on, it's less likely they're going to go into a full blown relapse. So today's presentation on therapy with eating disorders is based in part on a book by Barbara McFarland. Really like this book. If you don't do much with eating disorders, but you want to get a general understanding because maybe you occasionally have somebody come in who has a subclinical eating disorder. Or, or, you know, every once in a blue moon, you have someone who comes through with an eating disorder and you want to understand what needs to be done a little bit better. This book by Barbara McFarland. I really love it. And the overcoming disorder eating protocol by the Center for Clinical Intervention. I told you yesterday we would talk about that it's an 18 session protocol that was put together. Each session has its own little mini workbook that goes with it. So it is. And it's very cognitive behavioral in nature. So it's something that you can print out. I mean, it's freely available. The PDFs you can download print them out for your, for your clients. And you can use that in group. And most of the, that protocol is designed for group work and what you do an individual can, you know, spin off of that. So one of the things we're going to start talking about at first is shifting paradigms to one of resourcefulness versus sickness. And we've talked about this in some of the addictions classes too. When people are engaging in this behavior, whether it's eating disorders or addictions or self harm or whatever it is, what is the function? You know, that tells me the person wants to survive. That tells me the person is trying to figure out how to deal with something that is untenable and they don't know how to control it in a better way. They're doing the best they can with the tools they have at the moment. So we want to shift that paradigm. And then we're going to talk about some key interviewing questions to develop a strengths based alliance. The therapeutic relationship like we talked about in the last couple of courses determines clients willingness to openly discuss and explore behavior patterns. If a person with an eating disorder walks in and starts talking to a therapist or a psychiatrist about their, their issue. And the psychiatrist meets them with, okay, I hear your concerns. You know, a lot of times eating disorder behavior is caused by anxiety or depression or trauma. So let's treat that. And as that, as that problem starts to be ameliorated, your eating disorder is going to go away. The person with the eating disorder may be like, wait a minute, wait a minute. I came here because I want to stop binging and purging. I came here for that reason. I didn't, maybe we need to deal with that stuff, but you're not hearing me right now. I'm motivated to work on this issue. Or if they shut them down and say, in order to work together, you're going to have to be willing to gain X number of pounds per week or per month. And here are these rigid things that you need to do. Well, as, as we know, a lot of a part of eating disorders for most people is a control factor. They're trying to control something when other things feel out of control. So if the physician or the counselor starts yanking those reins and taking the control, the person's not going to be willing to openly discuss what's going on. Another thing that happens that may prevent open discussion. And if you have other situations that you think you want to add here, please feel free to type those in the chat window is of a client comes in and they have had a slip. You know, maybe not a full blown relapse, but if we're talking about somebody who is bulimic and they binged and purged the night before or the last weekend, or if they are anorexic and they haven't been able to bring themselves to eat for the last two days or something. And they tell the therapist that or they tell the psychiatrist that and they're met with a whole bunch of flak for it. You know, that's not good. We need to figure out why you did that and get you back on the right track because I can't keep seeing you if you're going to be non-compliant and yada, yada, yada. The person's not going to tell you when they relapse anymore. They're not going to tell you when they start to have problems because instead of saying, all right, that must be really disappointing to you that, you know, you were doing so well and then something happened and you started having symptoms again. So let's take a look at what happened. Let's talk about what might have contributed to it because, you know, we're still working to try to figure out everything that's going on. If it's met with more empathy and consideration and support and saying, all right, let's put our heads together and figure out how we can help keep you from doing this again. That's going to go a lot, lot further towards developing that therapeutic relationship. The person with an eating disorder. I mean, think about it as, I don't know anything about horses. We've got donkeys. But with our donkeys, when you try to get them to do something, I was trying to get Flojo to get out of the stall last night. And she was like, no, I want to stay in the stall, which was because that's where her food was. And I was trying to get her out and she's a mini donkey. She's only like 400 pounds. But, you know, me, I'm sitting there trying to push her out of the, out of the stall. And she's just looking back at me like, yeah, right. And as soon as I started saying, okay, let's, let's try a different tactic with this. And I tried to encourage her out. I tried to support her out. You know, I walked out of the, walked out of the stall and sprinkled some of her, some of her food on the floor. And she walked out and she was like, oh, okay, I got food out here too. That's cool. All right. So you understand I'm still not finished eating. And then we worked with it. So we want to be willing to support the person and say, what can I do to help you in this particular situation? I'm going to let you decide when you're ready to leave the stall. I'm going to let you decide when you're ready to take the next step forward. Instead of pulling you out or trying to forcibly push you, I'm going to stand here and I'm going to be your biggest cheerleader. But it's up to you when you take that step. A therapeutic relationship determines a client's willingness to consider altering eating behavior. So again, if we go gangbusters and say you need to start eating 1600 calories a day, which obviously the registered dietitian would say we wouldn't, but we would say the dietitian says you need to eat 1600 calories a day. And we're just going to hardline it. And that's the way it's got to be. They're going to have a hard time forming an alliance with us. If we can say that must be terrifying to think of doubling or tripling your caloric intake, you know, almost overnight. Let's talk about what that's like for you. And, you know, not have us hammering on you need to do this, but I can see why you're scared. How can I support you in this? Because theoretically you're here because you're motivated to change some. You may not be ready to do everything. And their willingness to disclose accurate information. People with eating disorders, especially if they are supposed to be gaining weight. You know, we talked yesterday about measuring urine specific gravity and stuff. Because people with eating disorders will often drink a whole lot of water before coming into way. So it shows that they are heavier than they actually are. Sometimes they'll drink something with a little bit more to it, like skim milk. Not as much because there's a lot of calories even in, you know, four cups of skim milk. But that also skim milk isn't as diluting on their urine. They'll find different ways, just like people who abuse drugs will find ways to beat the drug screens. People with eating disorders will find ways to beat the scale if they are not ready to start gaining weight. If they are not ready to start eating from those forbidden foods, they're going to lie. You know, unless they're in residential and even residential, they can get around some stuff. They are going to lie. I want clients to feel comfortable telling me what they're eating, what they're not eating, if they're purging. You know, yeah, I went to the gym yesterday and I intended to work out for 30 minutes. And before I knew it, I just couldn't get off. It was 90 minutes. Okay, you know, so you worked out for 90 minutes. What does that mean? How do you feel now? What prompted you to stay on the machine for an additional hour after that you are supposed to get off? And we'll talk about what things were going on. If they feel better after they've been on for 90 minutes than they do for 30 minutes, then we might start talking with the multidisciplinary team about, you know, can we move it so the person can work out for an hour at a moderate intensity. The really cool thing with some of the heart rate and fitness monitoring stuff is you can get a pretty good idea of what they're doing. I'm recovering from some stuff right now and I'm supposed to keep my heart rate below 150, which I'm really bad about doing, but I try. So when I go to the gym, I strap on my little heart rate monitor and my Polar app prints out a graph at the end. And I have that graph and, you know, my husband will be like, did you behave at the gym today? Yes and or no, but it shows me whether I behaved at the gym or not. And then I can figure out based on that, you know, am I doing better? And if if I push it a little bit and I continue to feel better and I don't have, you know, relapses of my symptoms, then, you know, then I can go to my doctor and say, you know, it's been three weeks, my heart rate stayed above 50. You know, I think I'm doing good. So it's a matter of working with the person. I am not going to contradict what anybody else on the multidisciplinary team says, but I'm also going to hear what the client says. And I'm going to try to help the client advocate for themself if they think this new strategy, whether it's more exercise or whatever it is, is helping them in some other way. So we're going to make an argument for advocacy and then I will help them present it to the team. Motivation determinants, the client's sense of safety and alliance with the therapist. Now we don't want to get into colluding with the clients and going, OK, now the, the dietician said you have to eat 1,600 calories. So how can we figure out how to get 1,600 calories in the least offensive way? Or how can we figure out how to get around? No, we don't want to collude with them on that. You know, I'm going to support them. I am going to say because of, you know, identify all the reasons it's important to eat that amount of calories or, or gain that amount of weight. But we're going to talk about how uncomfortable it is and talk about setbacks. And maybe they're not gaining as quickly as the rest of the team wants them to. If they're physically safe, you know, I might be in there kind of advocating for them to talk with the other team members. And I encourage them to look at the positive steps that they're taking. Yeah, you didn't gain a half a pound this week, but you gained a third. So at least you're gaining, you know, and kudos for that. That's awesome. If we have similar goals for treatment and the client and we're assuming here with brief therapy, you're really assuming a motivated client. This doesn't work real well with involuntary clients, but sometimes it does. If you've got a client come in because their parents said they have to come in and stop this or the doctor says that if they don't start gaining weight or stop purging that they're going to be hospitalized. They may show up not because they want to get better, but because they want the parents off their back or they don't want to go into the hospital. So, okay, that's a mutually agreeable goal. I don't want you to go in the hospital either. And I certainly want your parents happy. So how can we achieve that in a way that is the least threatening to you? So we start talking about, well, what needs to happen and where can we compromise and developing a treatment plan that way. And we talk about the cost benefit of the current behaviors. Now remember that whole decisional balance thing. What is the, what are the costs and benefits of maintaining the eating disorder and what are the costs and benefits of change? One of the costs that they may look at or one of the dilemmas they may have is they are terrified of getting fat. They're afraid once they start gaining weight, they're not going to be able to stop versus their desire to be healthy. They also may be terrified that if they gain weight, they're not going to be lovable or that people will think that they're lazy or sloppy or whatever adjectives they assign to a presentation that is less, less thin than they are right now. And so we're going to talk about what that fear of fat is all about. And then we're going to talk about what's motivating you to be here right now. You came, you have a desire to be healthy. You have a desire to stop purging. You have a desire of something here. So let's define what that is and talk about how we can balance that. And let's talk about the realistic things that may happen. You know, if you fear getting fat, if you fear that you, when you start gaining weight, you're not going to be able to stop. Okay, let's use that good old challenging questions worksheet. What is the evidence for and against that? You know, do you know people who are of average weight and however they define that who can't maintain that? Does everyone of average weight end up getting overweight? Probably not. So let's look at the facts for and against it. Let's look at your history. You know, if you have gained weight before or if you have had more weight on you before, did it spiral out of control? For some people, they may say yes, because we see a lot of people who yo-yo dieted before their eating disorder actually fully became symptomatic. So they would lose weight through, you know, whatever means they'd lose weight really fast. And then they gain weight back because when you deprive your body, when your body's in a starvation state, your base metabolic rate goes down, which means you can't eat as much. So then when you start eating a normal amount, yeah, you're going to gain weight because you're operating a more efficient system now. The BMR will go back up, but it takes a little bit of time. And sometimes people go on these fad diets where all of their food is portioned for them and they don't learn how to eat. They don't learn how to portion size. They don't learn the skills they need. So as soon as they stop getting prepackaged meals or being told exactly what to eat and when, they gain a bunch of weight. Now, is that because they had no control or is that because they needed more education? Is that because of something else? You know, do they have the ability to keep from spiraling out of control? And a lot of time is often spent on that. And a lot of time is often spent on what does it mean to you if you are what you consider fat? What do you think people think? You know, tell me about what it feels like to live in your skin if you were 20 pounds heavier than you are right now. And most of the time you'll see their eyes get like really big. So let's talk about that. That's obviously terrifying. Why is that terrifying? So developing this alliance and obviously this is probably at the beginning of treatment. So the person is still getting re-nourished a little bit if they're bulimic or binge eating. They may be well nourished. Like I said, they may not be because they may have been binging on foods that were like Oreos, which have virtually no nutritional value. You want to look at social pressures versus their desire to change. Are they on a drama team or not a drama team, a dance team, a cheerleading team, a sports team in a sorority? Do they have friends that support eating disorder behavior? Do they have a strong alliance or an exclusive alliance with a pro-anna or pro-eating disordered group of friends? If so, there's going to be a lot of social pressures to maintain that behavior. But then they have this desire to change out here or they wouldn't be in our office. So let's talk about that and how are you going to deal with the social pressures? What social pressures are you most concerned about? What about their sense of self-efficacy? Right now the eating disorder and by the time they come to our office, there's a little caveat because they're feeling out of control with their eating disorder. Oftentimes they're like, I don't want to do this anymore. I'm miserable and I don't know how to stop it. Whereas when they started it, it was a way of controlling something. So now they're like all in a quandary. So if you start gaining weight, are you going to feel efficacious? Do you feel like you will have more control over your life if you're not obsessed with what you eat all the time? Or are you afraid you're going to be out of control? What other cost benefits might we need to talk about in order to determine motivation and identify things that could be hiccups in getting somebody to be compliant, if you will, with treatment? Another thing I'll mention here while I'm letting you guys think, if you're working with a multidisciplinary team, which you probably will be, it's important to recognize that people with eating disorders are extraordinarily talented at splitting teams, parents, whatever. They'll do one thing in front of one parent and something else in front of the other. They'll ask one parent and get told no and then go ask the other parent and get told yes because they're extremely effective at manipulating people and manipulating the situation. And that's how they've been able to maintain their eating disorder probably for a long time. So you want to be aware of that fact. What do you mean? At some level, don't they split internally too? What do you mean by that? Sometimes they will be fighting a war against themselves. Part of themselves wants to get better. Part of themselves is terrified. And again, I keep going back to eating. I keep going back to addictions when we're talking about eating disorders, but you have two different voices in your head. You need to maintain this behavior or I really don't want to. I want to be healthy again. You really need to do this in order to get approval. Yes, I hear that I really should starve myself or do whatever in order to get approval, but I really want to eat because I'm starved right now. I mean, the body's desire to survive is really, really loud. So helping them rectify those two voices and the eating disorder voice, if you will, we need to teach them how to silence that voice. It's kind of like the negative internal critic. We want to start helping them figure out how to silence that voice and how to make the other voice stronger. What are all the reasons that you want to change your behaviors? Once the client is well nourished and the therapeutic alliance is functioning well, is it appropriate to engage the client to find something to add to their life that will help build confidence and healthy focus on something new for them to engage in, building self-acceptance and a new healthy version of control? Absolutely, absolutely. A lot of clients are very self-conscious, especially when they start gaining weight or when they're retaining water and all this stuff. I want them to start getting approval for other things and being able to approve of themselves and go, hey, I'm good at this and have people looking at them and talking to them about something besides their weight, shape, and eating. Yes, encouraging them to, even from the get-go, let's look at what are some other things you can do because when they start having that urge to purge or urge to binge, what can you do to distract yourself from doing that, from any sort of self-harming behavior at that point? What activities can we put in there? Maybe you can try anything they want to try. One of the things that works for some clients is keeping their hands busy so they don't feel obligated or in the habit of eating all the time. So yes, finding other healthy things for them to engage in, finding healthy role models for them to follow. Those are all excellent things to have them do, even from the very beginning, not waiting until they're perfectly nourished. So critical strengths-based interviewing questions. What kind and type of therapy did you have in treating your eating disorder in the past, if any? And if they haven't, say, all right, what have you done to try to control it? Because most people don't wake up one morning and go, well, I've been struggling with this eating disorder for like 10 years now, and I haven't tried to do anything about it. But hey, let's give therapy a shot. Most people are going to try to address it on their own. Now they may have tried to address their weight on their own, and that failed, and then they started developing eating disorder behaviors. So we may want to look at, you know, and what interventions, what things have you done to try to control your weight and eating in the past? What triggers your weight and eating? Ask them what parts of treatment have been helpful, if any, or what things have you done that have been helpful, if any? What interventions were helpful and under what circumstances? Sometimes deep breathing will work. Sometimes it's going to fall flat. So we want to figure out what interventions to use and when, and helping them understand that just like you don't use a Phillips head screwdriver for every single screw out there, you don't use the same intervention for every single problem out there because they're not always going to be as effective. So what under certain circumstances, what has worked? And yes, when you're working with clients who are, you know, trying to deal with their eating disorder or whatever, you know, sometimes when they have that urge to self-injure, to binge, to purge, they don't have the tools to deal with the emotions. So they need to use DBT techniques, distraction in order to get past that emotionally charged session or segment so they can get into their wise mind and decide what they need to do. And then they can talk about, you know, healthier ways to deal with those emotions in the future. But sometimes if people are naturally emotionally dysregulatory, if you will, they will need an amount of time to distract. It doesn't mean you don't ever come back to it. It means that you distract from it while you're in your emotional mind, while that adrenaline is coursing through your body and you're not necessarily making the most cognitive based decisions. What interventions have been helpful and under what circumstances? Do you believe you have any other issues such as depression or anxiety that may be contributing? And the client may say, yes. And a lot of times they will say, yeah, I'm depressed or I'm stressed out. And a lot of times there's a lot of depression, a sense of hopelessness and helplessness going on. So let's talk about that. What's prompting that depression? And remember that we talked to, I think the first session, we talked about the people, the fact that the people with eating disorders often have lower levels of serotonin and norepinephrine. Serotonin is one of your calming chemicals. Norepinephrine is one of your focus and motivation chemicals. So if both of those are low, then you may feel, the person may feel stressed out and have lack of motivation. And sort of lack of energy. Well, that sounds like agitated depression to me. So we want to start asking them what's going on. Now, does it mean they need psychotherapeutics? No, not necessarily. But we want to look at what is going on with them and what could help. Now remember from yesterday, they found that there really aren't any antidepressants or medications that seem to be effective with anorexia. But both fluoxetine and sertraline, prozac and zoloft, have been found to be effective with people with bulimia. So that may be something to consider if that's the direction they want to go. Now, if you've got somebody that has anorexia and also has major depressive disorder, that's a different ballgame because you're using the psychotherapeutics to treat the mood disorder, not to try to relieve the symptoms of anorexia. So, you know, you got to figure out if we're going to look at medications, what exactly are we trying to treat? What exactly is our hope for this? And what interventions or strategies that have been helpful in the past might be helpful now? So put it back in their court. This is giving them some control back saying, this worked, this worked, this didn't work. I really want to try yada yada. And so we can start talking about what might be helpful. And it can be a staged progression. You know, initially, maybe they want to have a more regimented diet. Maybe they want exactly what they're supposed to eat and when and they want to be able to write that down and have it there. And then as they progress through treatment, they may become a little bit less direct about what exactly they have to eat. So for lunch, they may have a sandwich on their menu instead of, you know, three ounces of chicken on two slices of rye bread and yada yada yada. So we want to help them figure out and learn how to eat again. We want to help them identify strategies that they can use to start improving their behaviors. They may not let go of any one behavior cold turkey. So we want to start looking at, well, how can we start reducing the frequency of the binges, reducing the frequency of the purges, especially an outpatient. Don't expect perfection. Don't expect them to not purge anymore. That's not realistic and it's going to set you both up for a sense of failure and disappointment. So you want to look at reducing frequency and intensity. Use the miracle question with clients. Encourage them to focus on tomorrow, not way in the future. We're not talking about two years from now. We're not talking about necessarily when you graduate or whatever. We're talking about tomorrow. If you woke up tomorrow morning, what would be the first thing you notice is different when you woke up? If, you know, your problem went away. Take me through the rest of the day and describe what else is different. What would be different if you woke up in the morning and your first thought wasn't, I'm hungry, but I can't eat or, you know, I can't eat until 11 o'clock or whatever the rule is, or I wonder how much I weigh today. You know, what if those thoughts that are bothering you right now were gone? What would be different? And you can spend an entire session kind of fleshing this out to figure out what the person wants to be different. And in what ways this eating disorder behavior and cognitive style is impacting their life? With body dysmorphia, the miracle question generally doesn't work too well. Because when they wake up in the next morning, you know, they want to see what they want to see in the mirror. What they're seeing in the mirror is not an accurate representation. And a lot of patients with body dysmorphia don't really understand. I mean, they can say, yeah, I know what I think I'm seeing is not how big I actually am, but it's how they feel. They feel that they're that big, even if they can intellectually say, I know that's probably not an accurate representation or nobody realizes this particular flaw. If you can get them to really believe and understand the difference there, that's awesome. But that's most likely way down the road. We want to explore exceptions. When has what worked and why? You know, that's a lot of W questions. Looking back over the past, when you have tried to control your eating or tried to control your weight or, you know, tried to not binge and purge, what has worked? You know, sometimes they will say, I quit keeping X type of food in the house or I went out to eat every day and I didn't keep any food in the house. Well, you know, if that's going to keep you from binging and purging for right now at the very beginning of treatment, all right, maybe that's something you might want to try. And this is obviously probably only doable for people who are single college students. But it is one way to help them initially. One woman I worked with her husband was a police officer. And when he worked midnight shift, she had a lot harder time because when she was home alone in the evening, she would binge. So the only thing she kept in the house was, you know, things to drink that were, you know, low calorie or no calorie and raw potatoes. And she's like, every once in a while, I got so hungry, I'd start eating a raw potato and it didn't taste very good. So I would find something else to do. Okay, is that the perfect solution? No, you know, were there other issues that needed to be dealt with? Yes. Did it stop her from doing something that was potentially self injurious and give her a sense that, okay, these urges do pass, you know, if I don't feed into them, helps her develop a more sense, a greater sense of control. So we want to figure out what's worked for the person. And sometimes it'll sound a little creative. We're going to use that word instead of odd, you know, okay, you know, sometimes people, if they start having an urge to binge or purge, they can go take a bath. When somebody with anorexia is having anxiety about eating something, what helps them? What can help them get through eating that whole apple or whatever it is? Talk with them about what strategies they've used that you could implement in order to help them be compliant with their treatment plan. Under what conditions has each activity produced an exception and failed to produce an exception? So exceptions are when it keeps you from doing the unhelpful behavior. So for anorexia, we want to find something that will help the person be treatment compliant. And if it hasn't, if it didn't work, you know, maybe they say, if I cut it up in the apple up into six pieces, and I know I can eat six pieces, it doesn't look quite so daunting at that point, you know, that works. But sometimes it, even if I cut it into six pieces, that doesn't work. I just want to gag every time I, every time I eat a piece. What's the difference between those two sessions when it works and when it doesn't work? They may not know, but we can start exploring. Then there's spontaneous and deliberate exceptions. Deliberate exceptions are when the person intentionally does something to be treatment compliant to help themselves not binge or purge, such as not keeping junk food in the house. Okay, that's a deliberate exception. Or if they start feeling like they're wanting to, wanting to binge going on a walk or taking a bath, that's a deliberate exception. They did something deliberate to interrupt that behavior. A spontaneous exception is one that just happens, you know, they started to want to binge or purge and then their kid came in the room and started talking to them. And by the time they finished talking to their kid, they didn't feel like binging or purging anymore. Or they got a phone call from somebody and they took it. They weren't intentionally trying to stop that binge or purge behavior, but something happened and it spontaneously seemed to go away. So you can say, alright, well, if you got a call and when you got off that call that urge had gone by, that's a new tool that you can put in your toolbox. When you start feeling the urge to binge or purge, call somebody. You can use scaling questions to help the client stop viewing things in terms of dichotomies. And this is important throughout therapy. And with most clients, not just clients with eating disorders, because a lot of clients who have anxiety and depression or eating disorders do think very dichotomously and they have a lot of cognitive distortions. So encourage the client to rate on a scale of one to five and give anchors, please give anchors. I often tell you to use one to four because when you use a one to five scale, the tendency is for people to always pick a three right in the middle. But give verbal anchors or concrete anchors for what that means. How anxious does it make you to think about eating a whole plate of spaghetti on a scale of one to five? One being doesn't bother me at all. Two being a little nervous. Three being I'm not sure if I can do this for being scared and five being no way in the world. Where are you at? And let's talk about what that means and why why you feel that way. What will happen if you eat an entire plate of spaghetti? How accepted do you feel by your family or your significant other or whatever? Again, use verbal anchors and then talk about why. So instead of the person saying they don't get me, nothing I do ever makes them happy, you can say, you know, let's look at how accepted you feel by them. And if they rank it a one, you know, I don't feel accepted at all. Then we start looking at the facts for and against that, you know, have they ever accepted or approved of anything that you've done? Ask them whether they're using verbal reason, not verbal reasoning, whether they're using emotional reasoning or cognitive reasoning. If they're using emotional reasoning, it means I don't feel worthy. So I'm assuming everybody else thinks that I'm not worthy or I feel scared. Therefore, this must be a terrifying experience. Not looking at the facts, just looking at I feel a certain way. Therefore, whatever's going on must be prompting that feeling. You can use the scaling question for things like how helpful was therapy or this intervention in the past one to five. It helped 10% of the time, 25% of the time, 50% of the time, yada, yada. And then talk about why, you know, what made it less than 100% effective? How often have you been successful at going a day without binging? Again, you can use percentiles, you know, one being less than 10% of the time, two being, you know, 25% of the time or less, etc. So it gives them an anchor, which gives you more test retest reliability. So when you ask them two weeks from now how successful they've been at going a day without binging, you're using the same anchor points and you can see progress. Scaling can also help us highlight ignored exceptions and positives. So if they say that everybody's always against me, and then we have them identify on a scale of one to five, how accepted they feel by a certain person. Then we can start highlighting, okay, well, it seems like this person, you don't feel accepted at all, but this person over here, you're getting along with, okay. So helping them identify that the whole world may not be against them. Feedback messages, whenever you're doing an assessment or even sessions with somebody with an eating disorder, periodically stop and summarize, especially if something significant positive happened. You want to stop and go, wow, wait a minute. So did I hear you right? Or, you know, you may not make that big of a deal out of it, but you want to stop and highlight positive actions or events and say, so what you just said was yesterday, you had a really stressful day at work and you even stopped off and got three pizzas on the way home. But you got home and decided that you were going to take a bath and before you started to eat to see if you could let the feeling go away. That is a huge step and really highlight that. Not focusing on the fact that she stopped and got the three pizzas and, you know, that created a danger situation, but focusing on the fact that she took a bath and put in that intermediary step to try to get into her wise mind and let the urge pass. You want to agree and restate the client's goal as much as possible without colluding with them. So remember, you're trying to find mutually acceptable goals. We want to keep them out of the hospital. I mean, yeah, we want them to get healthy, but healthy is a really freaky word to a lot of people with eating disorders because when they hear someone say you look like you're a healthy weight, they hear you look like you're a heifer. And that's not all people with eating disorders, but a lot of people with eating disorders. If you say you've got an athletic build or you're a good healthy weight, they're like, oh my gosh, how could you say that to me? So checking your terminology and your verbiage, but stating a mutually agreeable goal and what they've done, the positive progress they've made towards reaching that goal. Now you have choices to make. And sometimes it will be necessary to highlight and talk about some problems that they had, like binging and purging and whatever non-compliance with the treatment plan. However, you want to pick your battles when you're going through this because if you're constantly focusing on the negative, that's what they're going to hear. If you're focusing on the positive, it gives them a sense of control. Like maybe they've got this by the tail now. So you can choose to selectively not reinforce some of the negative behaviors if they say, yeah, I purged yesterday and I feel guilty about it and yada, yada, yada. This is what I did. Okay. Or if they talk about, okay, they purged. Okay. So what are you doing about it now? How are you getting back on the right path? We're not going to spend a whole lot of time talking about that because, you know, the person's already identified that they feel bad about it. If they want to talk about it, you can, but I really want to talk about what are you going to do to improve the next moment? What are you going to improve so that doesn't happen again or as much recognizing and reminding them that occasional slips, especially in early recovery, are going to happen. And the key is not to go all the way back. You know, it's kind of like climbing up a mountain. When people are climbing up a mountain, they put in little anchors as they go. So if they have a slip in their foothold, they don't fall all the way back down to the bottom of the mountain. They fall back down to the foothold right below. That's what I want you to do. I want you to see yourself making progress and there's going to be slips. That's okay. You know, it happens. Let's see what we can do to get back climbing up. A coin toss is another activity you can have them do. McFarland suggests this one specifically. Have them keep a quarter by their bed and toss it each morning. If it lands on heads, pretend it's your miracle day. That day they talked about that if I woke up tomorrow, all these things would be different, wouldn't have certain thoughts, yada yada. If it lands on tails, it's your regular day. Then talk about what resistance might you anticipate on the, on the miracle days. You know, because you're going to be acting differently than usual. What might happen? And what resistance might you have from the client to even doing this? Because pretending that it's a miracle day can be kind of scary because that might actually mean eating with other people and eating in a way that is less controlled. So we can talk about, you know, what might be different and how to do it in a way that they're not going to freak themselves out. Pay attention to how often or how you feel different and what others notice is different about you on your miracle days. So when they have, you know, theoretically you're seeing them once a week. So they have seven opportunities and they come into your office and we're just going to play the odds and say three days were miracle days. How did those days feel different than the other four days? Goals of the first session, attend to the present and future with little attention paid to the past. There's a lot of stuff that's happened in the past and this is kind of a psychodynamic strengths oriented brief approach. So we're going to say, let's look at your behaviors right now. You know, there's, there's trauma, there's disappointment. There's all kinds of stuff in your past. It made you who you are. You know, it happened and we're going to talk about how that's affecting you right now and how you want it to affect you in the future. But let's talk about right now. What can we do to improve your life or help you improve your situation right now? And maybe what do you want to see change over the next week? Explore a problem free future. What does it look like to you to be in a problem free future? That doesn't mean just the eating disorder. That means the other associated things that are probably maintaining the eating disorder that feel so out of control right now. How can you enhance exceptions and previous solution patterns? You know, things that you've done in the past. How can you do those more? How can you make it happen more? Like if somebody's binge eating or somebody who smokes, for example, most people can't walk on a treadmill and smoke at the same time. I've seen it done, but you know, if you go to a gym, it can't be done at all. So what things can you do that are incompatible with that behavior? How can you do those a little bit more? Because you're not doing whatever the behavior is 100% of the time. So the rest of that time, you know, when you're not doing that behavior, even if it's only 10% of the day, let's say, maybe you're depressed. You're working with somebody who's clinically depressed and they're depressed seemingly all the time. But it's likely they're not depressed 100% of the day. Do they laugh ever? Was there anything that, you know, made them smile? Maybe it was not enough to laugh. You know, what exceptions happened? So we want to look at those and build on them. Provide feedback and therapeutic compliments and then assign homework. The second session and behind beyond, you're going to separate the person from the problem. We're talking about you as a person and anorexic behavior. You are not an anorexic and trying to change that verbiage is really important because if you say you're an anorexic, then what happens to them when they don't have the anorexic behaviors anymore? If they cease to be anorexic, but they were an anorexic, then that means they cease to be. So, you know, philosophical there, but it is something to look at. We want to separate the behaviors, bulimic behaviors, eating disorder behaviors. Stay focused on the client's strengths and resources and try not to take a position regarding the client's situation. You're getting worse. You're getting better. You're just there. And how do you feel that you're doing right now? Constantly check in to see if the client's specific goals have changed. They will. That just part of being human goals will change. The person may say, I want to be happy, but I've realized that losing weight won't make me, won't make me happy. It is something else is going to make me happy. Okay, so let's look at that something else. Maybe you've realized you need to improve your communication skills or whatever it is. Continually evaluate the client's stage of readiness for change and watch for yes, buts, but indicate they're starting to go back into that pre contemplation and become less motivated. If they say, yeah, you know, I could have been compliant, but or yeah, I could have gone on a walk instead of binging. But let's talk about those yes, buts because that tells me that binging was far more rewarding than the alternatives. So let's figure out what's going on there because we need to enhance the motivation for those alternate behaviors. Developing a relapse prevention plan. You want to identify triggers and interventions, vulnerabilities and prevention strategies. Identify coping to school that coping tools for dealing with high risk situations and encourage them to develop a daily mindfulness protocol. So, you know, while I go through these, is there anything else you would put in a relapse prevention plan? So we want to talk about what are triggers for your eating disorder behavior triggers for starvation. If you, you know, some people with anorexia if they've got a the prom coming up or some meat or a pageant or something, they're going to that's going to trigger even more restrictive eating stress could trigger binging and purging. You know, so we want to figure out for this person what triggers eating disorder behavior and what can you do to address those triggers so they're not so overwhelming and triggering. What things make you more vulnerable and we want to look at, you know, malnutrition, lack of sleep, mood disorders, hormone balances. Anything that the person can say, yeah, when I'm feeling this way, I tend to be more likely to restrict or to purge or to binge or whatever. We've talked about coping skills and encouraging them to develop a daily mindfulness protocol so they know what they need. They wake up in the morning and they go, okay, how am I feeling? Do I have any of my vulnerabilities going on? Do I expect any triggers to come up today? You know, maybe they're supposed to go to lunch with an ex-boyfriend or something and that's a huge trigger. Okay, so how are you going to mitigate that so it doesn't cause you to relapse? Other tips, explain the necessity to focus on small goals one at a time. Eating disorders, unfortunately, unlike alcoholism where people don't have to have alcohol to live, we have to have food to live. So we can't just say, well, give it a break for a while and then, you know, let's work on this other stuff. And then you can check out later if you can return to social drinking or social eating. That's not the way it works. We got to eat. So we want, and these behaviors have probably been going on for most people for almost a decade or even more before they go to their first treatment episode. So we want to help them understand Rome wasn't built in the day. Let's take small steps and let's really focus on how awesome those steps are. Highlight the necessity of setting realistic goals and to tolerate behavioral and attitudinal slips or relapses. And we as therapists need to be able to tolerate that as well, even though it may feel like a crushing blow. We don't want the client to feel like we disapprove of them or we're disappointed in them if they have a slip or a relapse. We want them to feel like we are thrilled that they felt comfortable enough to trust us with that information and to come back and not give up. Food planning needs to be concrete and practical and must be presented as a way to create an exception related to a client's identified goal. And what does that mean? If we're going to have them do food planning and we're going to make them do that, then we need to help them see how it's going to help them achieve their goal of staying out of the hospital, getting their parents off their back, not binging anymore, whatever the case may be. How is this food planning helping them achieve their goal? How many calories? What about this compromise rewarded or reinforced the client's willingness to increase calories? So we want to look at how many calories did this person eat? How many were they supposed to eat? How did they feel? What would make them more willing to increase their calories? And it may be 50 calories a day that they're willing to increase, but every little bit helps. You can talk about whether calorie counting is good or bad, and that will depend on your multidisciplinary treatment team. With food planning, you're going to talk about what foods are going to be eaten. And if there are certain forbidden foods that are scary, then you're going to talk about those and talk about what it feels like to eat them. And sometimes some treatment programs will even incorporate eating those foods in session. So you eat a meal together and you talk about the experience of eating, for example, a high carbohydrate meal. The self-monitoring journal is kind of your mindfulness thing, but it's also their food journal. The time that they ate, what did they eat? How much did they eat? So we get an idea, are you eating high-fat, high-calorie foods for self-soothing or are you eating broccoli or something? How much did you eat? Is it a binge or is it a snack? Were you hungry? If not, what prompted your eating? Were you craving salty, sweet, spicy or specific foods? That makes them stop and think before they eat. Ideally they do this before they eat, but a lot of times in early recovery, it's done afterwards. How did you feel after you ate? Did you purge? If yes, how did you feel afterwards and what could you do differently next time? If no, how did you feel afterwards and what did you do to prevent the purge? And what information or exceptions can you derive from this table? What did you learn about yourself by doing this monitoring journal? And yes, depending on the relationship with the therapist, these journals may be more or less truthful. So again, developing that therapeutic alliance and encouraging 100% truthfulness is good. The ripple effect, addressing seemingly unrelated concerns can have a positive or negative effect on eating behaviors. So if the person feels like you're ignoring their eating disorder to treat their depression, they may feel like you're not hearing them. Or they may be like, oh, finally, somebody's helping me deal with this other stuff and not just focusing on my eating. Part of brief therapy means meeting the clients where they're at and developing mutually agreeable goals. For a client who doesn't want to gain weight and is still adamant about eliminating whole food groups, how can you align your goals? That's one of those questions that you've got to think about because it's going to happen. For a client who's terrified of gaining weight if she stops exercising and affiliated behaviors but can't moderate her activity at the gym, how can you find a mutually agreeable goal? And some of these may be staying out of the hospital or being able to be healthy or whatever their ultimate goal is. So the eating disorder treatment protocol starts out with what is an eating disorder? Then the next, I'm just going to read through these segments. How ready am I to change? How are eating disorders maintained? Learning about self-monitoring? Learning about regular eating and weighing? The binge purge and driven exercise cycle? Mood-ordered eating, so learning about eating to self-soothe? Talking about different dietary rules and whether they provide comfort and safety or they're actually harmful? Reviewing progress and barriers? Looking at over-evaluation of weight and shape, what does weight and shape really mean? Challenging thoughts and unhelpful cognitions? Challenging those dietary rules? Talking about checking, avoidance and feeling fat? So starting to develop more of a feeling vocabulary? Improving self-esteem? And changing mindsets so they become more self-accepting instead of self-rejecting and critical all the time? And then relapse prevention? It's important to develop mutually agreeable goals focusing on what the client hopes to achieve. Use the miracle question to help identify client's goals and support the client's successes while trying to avoid reinforcing undesired behaviors by giving them too much attention. Explore the use of journals and the handouts to help clients process between sessions and develop a relapse prevention plan early in treatment to help clients address the main presenting symptom, whatever it is they identify. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. 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