The Clinician’s Toolkit

1. The Clinician’s Toolkit Seasoned Therapists Share their Favorite Techniques Linda Buchanan, Ph.D. Rick Kilmer, Ph.D. Anna Tanner, M.D., FAAP, FSAHM Page Love, Rd Eileen Shaw, Rd, LPC Angela Schaffner, Ph.D. Jamie Glazerman, LPC Ryan Schwerzmann, LMFT

2. The Interactive Model of Treatment • Phase 1: Education • Phase 2: Cognitive behavioral treatment for symptom stabilization (Skill based: CBT, DBT, Maudsley, ACT) • Phase 3: Psychodynamic interventions for deeper healing • Replacement Therapy: accessing the adaptive function of symptoms and finding alternatives.

3. Evolution of the Treatment Model – Road Map Phase 1: Education Phase 2: Cognitive behavioral treatment for symptom stabilization Phase 3: Psychodynamic interventions for deeper healing

4. Adaptive Function of Eating Disorder Symptoms to be Replaced: • Self soothing, nurturance, comfort • Affect management ‑ medicating forbidden, painful or dangerous emotions • Dissociation ‑ escape from threatening memories, behaviors, affect, sensations, knowledge or situations • Offering a sense of control or power • Offering self‑esteem: superiority, mastery, pride, being special (i.e. conquering needs, hunger, being thinnest, “sickest”, etc.) • Identity and belonging • Silencing the “chatter” (of the critical parent, antilibidinal ego, internal saboteur) • Pleasure, feeling alive, allowing “here and now” • Protection • Limits • Companionship; reliable, consistent relatedness • Attention, cry for help

5. Stages of Change and Phases of Eating Disorder Recovery Stages of Change • 1) Pre-Contemplation • 2) Contemplation • 3) Preparation • 4) Action • 5) Maintenance Ten Phases of Eating Disorder Recovery (Carolyn Costin) • 1) I don’t think I have a problem. • 2) I might have a problem but it’s not that bad. • 3) I have a problem but I don’t care. • 4) I want to change but I don’t know how and I’m scared. • 5) I tried to change but I couldn’t. • 6) I can stop some of the behaviors, but not all of them. • 7) I can stop the behaviors, but not my thoughts. • 8) I am often free from behaviors and thoughts, but not all the time. • 9) I am free from behaviors and thoughts. • 10) I am recovered.

6. Methaphor, Stories and Narrative

7. My Vision of The Good Life • PURPOSE: To help patients clarify their image of the life lived well, a life in recovery, one consistent with their true values. This exercise helps identify treatment goals, to form a collaborative therapeutic relationship, to enable patients to own their recovery. The Vision is a tool to motivate patients with relevant goals to move towards. • DESCRIPTION: “I am going to be your scribe. I would like you to tell me your vision of the life worth living, the good life. Think out loud about the aspects of your life you want to keep, the aspects you used to do and want to reclaim, and the parts you have never put into place but would like to.” Paraphrase what you hear in present tense, positive form. Phrase unrealized goals as, “I am moving toward” or “open to…”. If they state an “ego goal”, ask them for the meaning behind that goal…Ex: ”And if you were skinny, what would that mean?”…”Then no one would ever tease me.”…becomes “I use my voice to assert myself and surround myself with supportive people”. Offer them a copy to look at frequently. Review as treatment progresses. • SOURCE: Rick Kilmer, PhD, adapted from a Harville Hendrix, PhD couples exercise.

8. Miracle Day Exercise • TECHNIQUE: Miracle Day Exercise   • PURPOSE:  To help a client clarify his/her desired changes, envision life in recovery and increase motivation to change.  • DESCRIPTION: “Suppose tonight, while you are asleep, a miracle happens and you awake completely recovered. How will you be able to tell that a miracle has happened? What will you see, hear, think, feel and do that is different than your usual days? How would the other people in your life see, hear, and notice that is different about you? How would you and others describe the behaviors, attitudes and values I your new life?”  • SOURCE: Solution Focused Therapy.  • Contributed by: Rick Kilmer, PhD

9. Factors and Myths Related to Developing an Eating Disorder Myths: • People with eating disorders are vain and could get over it: • Highly Sensitive Personality • Serotonin - Anxiety Link • Physiol. Behav. 2008, April 22. 94(1). “Getting over” an eating disorder will involve learning how to manage their sensitivities in healthy ways. Premorbid anxiety related problems • Due to Family Problems • Will struggle their entire life • Mainly a rich, white girl disease • People with eating disorders are selfish The truth about eating disorders: • In summary, people who develop eating disorders are born with differences in their brain chemistry which increase their sensitivity to stimuli. This sensitivity develops into a heightened awareness of their own and other’s reactions which generally leads to harm avoidant strategies such as perfectionism, obsessive-compulsive behaviors, social avoidance, shyness and ultimately eating disorders. These strategies are faulty attempts to control the level of distress they may experience. • Treatment involves recognizing that their sensitivity is both a blessing and a burden and learning more effective tools for coping.

10. Comparison of Prevalence and NIH Funding SOURCE: Physiol. Behav. 2008 April 22: 94(1): 121-135

11. The Vicious Binge-Purge Cycle Use the diagram to: Increase the understanding of the way each behavior maintains the cycle Understand the role that under eating plays in maintaining the cycle, use of the deer metaphor Brain storm ways to divert from the cycle at any point Source: Bulimarexia, 1983

12. Physiological Factors Involved in the Production of Emotions • Prompting Event • Interpretation • Chemical changes • Burnt pan syndrome (LB) • Substances, adrenaline • Habit • Rut in the road • Idling emotion (LB) • Half smile (ML) • Secondary emotions (ML) Source: LB (Linda Buchanan), ML (Marsha Linehan)

13. Resolving Ambivalence with Empty Chair Technique • PURPOSE: To reduce power struggles between therapist and client, to increase insight into sources of ambivalence, to increase insight into wisdom on both sides, and to problem solve a resolution Often helpful to use between part that wants to recover and part that does not. • Is there any small part of you that feels differently? • DESCRIPTION: Upon noticing ambivalence or engaging in a power struggle ask the person to place one part of her ambivalence in one chair and the other in the other chair and take turns speaking to the other part. • Most commonly used sentence stems: • What you don’t understand… • What I wish you’d do differently… • When you say/do that, it reminds me of (what or whom?)… • If I listen to you, I’m afraid that … • I understand that you feel… • SOURCE: Adapted from Gestalt writings

14. Meal Groups: Using Grounding Statements and other Mindfulness Strategies • Check in with hunger level (1-10), anxiety level (1-10) and grounding statements • It’s okay to enjoy food, • My body needs this, • This is on my meal plan • I’m eating enough to take me to my next planned eating experience • I’m not depriving myself • I can stop when I’m full • Chaining as a mindfulness strategy • Check out with hunger level, anxiety level and grounding statements • I didn’t eat too much • It’s okay to feel full • It’s okay to need food • This food will give me energy for my day • I am satisfied and can now focus my attention on other things • Source: ACE and others

15. Destroy The Scale • PURPOSE: To end obsessive weighing and defining oneself by a machine that measures gravity.      • DESCRIPTION:   Determine a satisfying manner in which to physically destroy your scale. Methods used have included heaving the scale from a high place, breaking with a hammer or ax, shooting scale with buckshot. etc. Some people write affirmations of independence prior to destruction on the scale and invite friends/family/group members to witness or participate in the ritual. • SOURCE:  ACE  

16. Clinical Guideline for the the Evaluation and management of patients with eating disorders Anna B. Tanner, MD, FAAP, FSAHM The Teen Center at Gwinnett Pediatrics and Adolescent Medicine Adjunct Instructor of Pediatrics, Emory University School of Medicine

17. KHF Guidelines • Kids Health First Pediatric Alliance • Over 200 pediatricians from 38 leading independent pediatric practices throughout the metropolitan Atlanta area • Collaborative, information-sharing organization • Compiles and distributes evidenced based information to all member pediatricians. • The intent of the guidelines • Build a consensus of care in the pediatric market • Provide a framework for clinical decision-making

18. Purpose of New Guideline • General pediatricians will see patients with eating disorders. • Pediatricians should understand the initial identification and work-up of these patients. • Pediatricians should be aware of the indications for referral and resources available in the community.

19. Content • General introduction to eating disorders • Anorexia nervosa • Bulimia nervosa • Review of key points in screening medical history • Clinical protocol • Rule out other disorders • Determine severity of condition • Physical exam • Laboratory evaluation • Make plan of care • Medical admission • Referral for mental health and nutrition therapy • Ongoing medical supervision by Pediatrician • Regular communication between team members

20. Medical Criteria for Hospitalization • Anorexia Nervosa • <75% ideal body weight • Refusal to eat, ongoing weight loss despite intensive outpatient therapy • Heart rate <50 beats per minute daytime, <45 beats per minute nighttime • Systolic blood pressure <90 • Orthostatic changes in pulse (>20 beats per minute) or blood pressure (>10 mm Hg) • Hypothermia (body temperature <96 degrees F) • Arrhythmia • Electrolyte abnormalities • Bulimia Nervosa • Syncope • Electrolyte disturbances: • Serum potassium < 3.2 mmol/L • Serum chloride < 88 mmol/L • Esophageal tears • Cardiac arrhythmias including prolonged QTc • Hypothermia • Intractable vomiting • Hematemesis • Any Patient • Suicidality (ideation, plan, attempt) • Failure to respond to outpatient treatment

21. Nutritional Therapy Techniques Page Love, RD Eileen Shaw RD, LPC Atlanta Center for Eating Disorders

22. Medical Nutrition Symptom Alleviation Goal Setting • TECHNIQUE: Identifying medical issues from malnutrition as motivators for change • PURPOSE: To help a client identify medical symptoms related to decreased nutrition intake/absorption that he/she would like to alleviate and goal setting to move forward in physical recovery. Used in both group and individual therapies • DESCRIPTION: Client views poster visual of side effects of anorexia and bulimia poster and works through worksheet asking about eating styles and restrictive patterns that may identify nutrition deficiency medical issues. Client identifies physical issues he/she may have not been aware of that they are struggling with and set goals to alleviate most irritating symptoms with improving nutritional/medical status with a “nutrition as medicine” approach. • SOURCE: Page Love, RD

23. Medical Complications from Restrictive Eating Practices

24. Cognitive Reframing of Food/Body Fears • TECHNIQUE: Cognitive behavioral reframing with food fears related to body image. • PURPOSE: Helping client identify food fears/negative beliefs regarding perceptions around food increases causing distorted body changes. Nutrition science/physiology will be used to help client shift thinking to a more logical less distorted fashion. • DESCRIPTION: Client identifies top negative fear related to food causing weight gain. Client writes out top fear and uses examples of cognitive restructuring to create his/her own cognitive restricting regarding fears of common food/nutrient group areas such as fears of feeling “fat” after eating, carbohydrate and fat fears, and fears of weight gain. Dietitian uses physiological science to dispel common myths and fears and ultimately decrease food fears and lesson body distortion. Client is encouraged to continue this work with split journaling and to explore deeper issues in psychotherapy. • SOURCE: Page Love, RD

25. Reframing Body and Food Fears to Support Change • “ I feel fat after I eat” can change to….my stomach may be distended after eating but this will go away in a couple of hours after I digest my food (and explore what feeling fat really means….unhappy, depressed, sad….) • “ I will gain weight if I eat this food” can change to….no one food will cause me to gain weight instantly; weight fluctuates on a day to day basis mostly from fluid shifts (real issue may be gaining…losing control/changing…)

26. Just like Your Car, Your Body Needs The Right Kind of Oil….

27. Reframing Statements to Support a Change in Belief System: Split Journaling

28. Evaluation of Normalization of Eating Behavior as Moving into Recovery • TECHNIQUE: Evaluating markers of eating disorder “non-diet” recovery using Reiff and Reiff recovery markers. • PURPOSE: Identify level of eating habits recovery and ongoing areas to develop full normalization of eating pattern for moving on own recovery path as finishing therapy. • DECSCRIPTION: Client will identify accomplishments in non-diet mentality or recovery to date as finishing their work with the practitioner with a questionnaire activity. This allows client to see what additional areas they will need to continue to work on the recovery continuum on their own as they are leaving therapy. • SOURCE: Page Love, RD

29. When are our Clients in a Healthier Place?(Adapted from Reiff and Reiff) • Maintenance of healthy weight • Open to all foods and eats a variety • No nutrition related medical problems • Regular participation in social meals • Responding to (not ignoring) hunger • Able to identify fullness and respond • Less time spent on thinking about food, body, and weight • Normal moderate exercise patterns • Appropriate caloric intake to meet maintenance needs • No food fears • Adequate fat, protein, and carbohydrate intake

30. Mindful Eating Exercise: Mindfulness of Mind Scale • PURPOSE: For teaching mindful eating - either in individual nutrition counseling, meal group, or one on one meal coaching • DESCRIPTION: • 10: Mindlessly unaware eating. I am zoned out and multitasking while I eat, unaware of portion sizes (eating out of the bag, standing in front of the refrigerator picking at food, grazing and grabbing handfuls, picking at the breadbasket). • 9: Taking big bites, eating very rapidly, finishing everything on my plate despite fullness. Having scattered thoughts. Eating while studying, reading, watching TV, or driving. Being unaware. • 8: Very inattentive to each bite. Just eating without checking in with self. Not really tasting the food. • 7: Moderately unaware of the process of eating. Eating with little awareness. • 6: Occasionally noticing taste, texture, and smell. Fleeting acknowledgment of sensations. • 5: Aware of portion size. Momentary acknowledgement of taste and attention to food and body cues. • 4: Briefly noticing taste and food sensations. Stopping to place and redirect attention when it wanders. • 3: Moderately present in the moment and attentive to eating process. • 2: Very alert. Diligently noticing flavors and temperature. Almost all attention is directed to eating. • 1: Mindfully aware eating. Completely present in the moment. Aware of every bite. Tasting each grain of salt and smoothness of yogurt. Noticing lifting the fork. Listening to the sound of chewing. Following sensations of food as it travels down my throat. Eating bite by bite. • SOURCE: Adapted from Eat Drink and Be Mindful, Susan Albers, Psy.D....

31. The Basic Mindfulness Bite • PURPOSE: For teaching mindful eating - either in individual nutrition counseling, meal group, or one on one meal coaching • DESCRIPTION: The simplest technique of mindful eating is the Basic Mindfulness Bite. You can use this technique with any solid food. 1. As you bring food to your mouth, slow down and become aware of your movements. 2. Once the food is in your mouth, clear your hands. Put silverware or remaining food down. 3. Chew this bite with your mind in laser-sharp focus on the process. Concentrate on the taste of the food and the act of eating. Do not do anything else while you are chewing. Simply chew and pay attention. 4. Keep chewing until the food is uniformly smooth. Use this consistency of the food as a signal to swallow. 5. After you swallow, but before you bring more food to your mouth, rest for a few seconds, thereby inserting a pause into your eating. No matter what other technique or strategy you may use with mindful eating, this Basic Mindfulness Bite can serve you as the best starting point. • SOURCE: Adapted from Discover Mindful Eating, Burggraf, M.Ed., Megrette Hammond RD, CDE

32. Individual Therapy Techniques Angela Schaffner, Ph.D. Atlanta Center for Eating Disorders

33. Worry Chair • PURPOSE: For clients to be able to honor their worry and not focus on their worry. Overall, the goal is for the client to be able to see that she is has a worry/obsession but is not putting her focus on it. She will learn to let the worry be in the back of her mind and place active focus on activities and thoughts in the moment to help her feel more connected, content and relaxed. • DESCRIPTION: Talk to the client about setting aside worry time everyday. They choose 5/10/15 minutes. It has to be in a chair or on the couch (not in bed) and has to be in the late afternoon or early evening. She can pick the time and location. If she notices that she is worrying throughout the day, she can tell herself to "Stop" and picture a red stop sign. She is to practice being descriptive and saying stop to herself. As she goes about her normal daily routine and notices she is worrying or obsessing about something, she then tells herself that this worry can be saved for worry time where she can worry about it all she wants. Some people like to keep a worry journal to remind themselves what they need to worry about and especially if they wake up at night with a lot of worry and racing thoughts. Over time, she will learn to decrease her worry and even if the obsessive thoughts are occurring she can learn to not place her focus on to them. • SOURCE: Behavioral Therapy (assigning the problem) • Contributed by: Rachel Rose, PhD, Psychologist at ACE

34. Looking For Exceptions • PURPOSE: To acknowledge successes and identify what is already working • DESCRIPTION: Identify instances in the past week where symptoms were not used and another behavior was used instead. • SOURCE: Solution-Focused Therapy • CONTRIBUTED BY: Angela Schaffner, PhD, Psychologist at ACE

35. Four Columns of Foods • PURPOSE: To decrease good/bad categorization of foods and increase flexibility and a methodical way for introducing feared foods. • DESCRIPTION: Ask clients to avoid using the terms "good/bad" to describe food choices and instead to talk about how feared certain foods are from 1-4. Discuss ways to integrate 2, 3, and 4 to overcome fears and recover at a pace that is out of comfort zone but doable. • SOURCE: Recovery Skills module at ACE • CONTRIBUTED BY: Angela Schaffner, PhD, Psychologist at ACE

36. Family Based Therapy Techniques Jamie Glazerman, LPC Ryan Schwerzmann, LMFT Atlanta Center for Eating Disorders

37. Agnostic view of etiology • Alternative to inpatient hospitalization • Evidence Based • Empowers parents as primary vehicle to reefed their child • Therapist is in an “expert witness” role • Completed in 3 phases: • Phase 1: Re-feeding: parents take control of nutrition and engage in efforts to reefed their child while working with therapist to separate their child from the ED • Phase 2: Return control: Once weight is restored, gradually return control of feeding back to child in developmentally appropriate way • Phase 3: Return adolescent and family to normal, developmentally appropriate functioning:assist patient in getting back to normal without using the ED as a coping  tool, address any non-ED related family issues. Family Based Treatment The Maudsley Method Basics of Family Based Treatment for adolescent Anorexia and Bulimia Source: www.maudsleyparents.org

38. Using Family Based Treatment • How do you know when “classic” Family Based treatment will be a good fit? • Appropriate age range (8-15 ideal) • Family ego Strength: • Are parents/caregivers free of active eating disorders, addictions, mental illnesses? • Are parents in full understanding of their role and willing to make the commitment to home-based treatment?

39. Outpatient Family Based Treatment • Compromise is FBT- based IOP/PHP: • FBT minded family therapist acting as case manager • Individual therapy may or may not be indicated • Skills/process groups to help support the adolescent • Multi-family meal and therapy groups to reinforce FBT concepts

40. Family Sculpting: Eating Disorder Versus Recovery • PURPOSE: To allow clients to experience life, relationship dynamics, mindset and emotions while in their eating disorder and in recovery. This technique often breaks through denial of the pain caused to self and loved ones, and offers a vision of life and relationships in recovery. • DESCRIPTION:   The family sculpture may be done with the actual family or with group members enrolled as family members. Two sculptures are created and witnessed, one demonstrating life with the eating disorder, then one in recovery. The sculpture involves representing family relationship dynamics by placing the members together in terms of posture, spatial relations, and behaviors that represent the actions/ interactions, feelings, and phrase/message of each family member. The client then witnesses the sculpture for a few minutes as sculpted members repeat their phrases and actions all at once. • SOURCE: Family Therapy, adapted for eating disorder focus.

41. Family Therapy Techniques – Goal Setting • TECHNIQUE: Reverse Goal Setting • PURPOSE: For use with clients that are focused on the “problem” and have difficulty identifying goals. • DESCRIPTION: Begin by asking each participant to define what they see as the “problem” that brought them to therapy. Agreement is not necessary. Ask each participant to then describe things they have done to attempt to solve the problem that have not worked. Next, ask them to describe anything that they have not yet tried that might be helpful. Finally, ask participants to describe what life will be like when the problem no longer exists. Discuss their answers to the final question as possible goals for treatment. • SOURCE: Ryan Schwerzmann, LMFT

42. Family Therapy Techniques - Ambivalence • TECHNIQUE: Coin Flip • PURPOSE: To help clients resolve ambivalence over decisions, or when there is an avoidance of responsibility for making choices. • DESCRIPTION: When clients have difficulty making simple decisions, tell them they can flip a coin to decide. Have them assign one option to heads and one option to tails. Instruct clients to pay attention to their initial reaction to the results of the flip, then flip a coin. If they are satisfied, go with that option. If their first reaction is “best 2 out of 3,” do not flip again but have them go with the “losing” result. This helps clients bypass emotional interference that is preventing them from making decisions. • SOURCE: Ryan Schwerzmann, LMFT

43. Family Therapy Techniques – Communication • TECHNIQUE: Copy Cat • PURPOSE: To identify strengths and weaknesses in communication and challenge perfectionism and control issues within a relationship. • DESCRIPTION: One family member draws a picture of random doodles secretly. The rest of the family attempts to copy the picture exactly by following verbal instructions from the original artist. No one should be able to see any pictures but their own. Participants can ask questions for clarification. You can increase the level of challenge by introducing multiple colors or providing participants with different sizes of paper. Therapist will explore any relevant themes or issues with the family at the conclusion of the activity. Materials Needed: Paper and writing utensils for each participant. • SOURCE: Ryan Schwerzmann, LMFT

44. Family Therapy Techniques – Resistance • TECHNIQUE: Mole Hill  Mountain • PURPOSE: To help resistant families understand the impact of avoiding discussion of issues. • DESCRIPTION: Use this technique after a pattern of avoidance of or refusal to discuss several specific family issues has been established. Give each person one tennis ball for each issue that is not being discussed by at least one family member (e.g. 5 tennis balls each if 5 topics are consistently avoided). Inform each family member that they need to hold all their tennis balls throughout the session and not let them fall to the floor. Begin session as normal paying attention to when people avoid, deflect, become defensive or change the topic from the issues being discussed. Whenever this occurs, give 1 ball to the “offender.” If someone does explore or discuss and issue, remove one of their tennis balls. Discuss with the family how they were affected by the accumulation or removal of tennis balls and help them connect their experience to the discussion of their issues. Materials Needed: Lots of tennis balls (or any kind of small, soft ball) • SOURCE: Ryan Schwerzmann, LMFT

45. Family Therapy Techniques – Emotional Reactivity • TECHNIQUE: Emotional Dodge Ball • PURPOSE: To illustrate the process and impact of emotional reactivity and taking responsibility for other people’s feelings. • DESCRIPTION: Give each participant one tennis ball. Instruct them to hold on to their tennis ball(s) at all times. Have them take turns making observations about each other. Instruct participants to notice their initial reaction and express it to the group. If he or she sees it as productive, nothing happens. If he or she sees it as unproductive he or she takes a tennis ball from the observer and adds it to his or her pile. If anyone in the group reacts unproductively to the observer or the observee, they would take a tennis ball from him or her and add it to their pile. Whenever someone gives up a tennis ball, the therapist should replenish it. Periodically, the therapist may challenge someone to reframe their unproductive thought into a productive version. Discuss with the participants what the experience was like and process patterns that led to the accumulation of tennis balls. Connect the challenge of managing the tennis balls to the emotional toll of being responsible for other people’s feelings and/or interpreting events in an unproductive way. Materials Needed: Lots of tennis balls (or any kind of small, soft ball) • SOURCE: Ryan Schwerzmann, LMFT

46. Shell Ritual • PURPOSE: To provide a transitional object when a person leaves a group to aid in relapse prevention • DESCRIPTION: Each person in the group speaks into the shell what she hopes the person will remember when holding the shell based on our belief that the shell stores the wisdom spoken into it. • SOURCE: Linda Buchanan