Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders Nicole Siegfried, PhD, CEDS Clinical Director, The Highlands Adjunct Associate Professor, UAB
ethinking Family Therapy in ED Treatment: trengthening the Self Through Building the apacity to Relate Locations: St. Louis, MO//Pacific Grove, CA//Birmingham, AL Jim Gerber, Ph.D. Clinical Director 2 2
Overview Defining Recovery Relapse and Recovery in Eating Disorders (EDs) Interventions to Promote Recovery Questions and Comments
Defining Recovery Definitions of Recovery Remission? In Recovery? Recovering? Recovered? Definitions of Relapse Relapse? Slip? Lapse?
Defining Recovery Full Recovery vs. Partial Recovery Partial recovery No longer meets diagnostic criteria for ED Weight restoration No bingeing, purging, fasting within past 3 months Full recovery All of the above plus Psychological recovery (i.e., within 1SD on quality of life measures, psychological and psychosocial functioning) (Bardone-Cone, 2012)
I just live my new life without much thought to my recovery Bulimia was in the rear view mirror- a scene getting smaller and smaller the farther we traveled along life s road until it was a mere dot and then was gone. (from a spouse) Defining Recovery The ED is no longer the voice in my head I accept myself and my body; I don t use food to resolve problems and I don t let food dominate my life. The eating disorder feels far away, like a distant dream, very separate from my current life She has an absolutely ordinary relationship with food. (from a mother)
Defining Recovery IN RECOVERY Fearful of relapse Vulnerable to major events Accept body (still dislike) Focus on ED Recovery Attempting to Connect Moments of Joy and Peace Identity = ED FULLY RECOVERED Confident in recovery Proactive to events Love and accept body Focus on Life Connections Joy and Peace True Identity (Schaefer, 2012)
Relapse and Recovery in EDs Relapse Rates for AN & BN range from 22%- 51% Mortality rates as high as 20% (primarily from cardiac arrest or suicide) Recovery Rates in AN range between 44%- 76%, with prolonged recovery time (57-59 months) Recovery Rates in BN range between 50%-70% (Berkman, 2007; Carter et al., 2004; Clausen, 2004; Couturier & Lock, 2006; Fichter et al., 2006; Fichter & Quadflieg, 2004; Field et al., 1997; Herzog et al., 2009; Keel & Mitchell, 1997; Keel et al., 2009; Keel et al., 2005; Olmsted et al., 2005; Stenhausen, 2002; Strober et al., 1997; Van Holle et al., 2008)
Relapse and Recovery in EDs Recovery Boosters Weight Gain Early in Treatment for AN Reduced Family Conflict Shorter Duration of Illness Involvement in Work or School (Accurso et al., 2014; Strober et al., 1997; Treasure & Russell, 2011)
Relapse and Recovery in EDs Risks for Relapse Presence of Purging in AN or Higher Frequency of Vomiting in BN Family Conflict Poor Social and Occupational Functioning Poor Motivation for Recovery High Levels of Impulsivity Longer Duration of Illness or Delayed Treatment Premorbid Obesity Substance Abuse Severe Body Image Disturbance (Berkman et al., 2007; Keel et al., 2005; Van Holle et al., 2008)
Relapse and Recovery in EDs Top 10 Relapse Triggers 1. Strong Negative Emotions 2. Paying Attention to Numbers (e.g., Calories, Sizes, Weight, Time/Distance/Calories Burned in Exercise) 3. Dieting/Eating Diet Foods/Skimping on Meal Plan 4. Comparing Self to Others (in terms of weight or recovery success) 5. Isolation 6. Engaging in or Listening to Weight/Diet talk 7. Being Around Others Who are Practicing Their Eating Disorder 8. Perceived Failing or Fear of Failure 9. Over-committing/Over-working 10. Over-exercise/Not Sticking to Exercise Plan
Interventions to Promote Recovery
Interventions to Promote Recovery Identify the problem behavior in detail Identify the prompting event external trigger Identify vulnerability factors-internal & external factors that make client susceptible DBT Techniques Behavior Chain Analysis Identify links-specific thoughts, actions, sensations & feelings Identify consequences (positive & negative) Identify new skillful solutions Identify ways to reduce risk in future
Interventions to Promote Recovery Vulnerability DBT Techniques Behavior Chain Analysis Prompting Event Thoughts Emotions Body Sensations Problem Behavior Consequence Consequence Consequence
BINGEING BEHAVIOR CHAIN
Interventions to Promote Recovery DBT Techniques Urge Cards On front: Write urge/behavior Write function of urge/behavior On back: Write affirmation Write coping skill(s) specific to that urge/behavior
Interventions to Promote Recovery DBT Techniques Urge Surfing Urges typically pass within 15-30 minutes Individuals usually act on urge within that time, and mistakenly attribute reduction in urge to their action rather than passing of time Teaches clients that if they can ride the wave of the urge for 30 minutes, it will pass. (Linehan & Demeff, 1997; Marlatt & Gordon, 1985; www.aliceboyes.com/urge-surfing/)
Interventions to Promote Recovery DBT Techniques Alternate Rebellion Encourages clients to find alternate ways to rebel against the restrictions and deprivations of their lives without life-threatening behaviors, therapyinterfering behaviors, and quality-of-life Interfering behaviors. Marlatt & Gordon, 1985
Interventions to Promote Recovery Relapse Prevention Techniques Three Circles Carnes, 2006
Going to classes Allowing my dietitian to be in charge of my weight Volunteering at Habitat at least 1X/month Going out to eat at least 1X/week Committing to do two things at same time Skimping on a meal or snack Skipping even one class Running on a treadmill Having playtime with my dogs on a daily basis Attending aftercare groups and therapy appointments lying about my food/eating Purging Going to a gym Bingeing Losing weight Skipping a meal Exercising when I have an injury Walking as exercise Taking diet pills Weighing myself Trying to lose weight Daily meditation Coming up with excuse not to go with friends Staying up past 1:00AM Following my meal plan Being honest with others Taking a bubble bath at least 1X/week Following my exercise plan
Interventions to Promote Recovery Relapse Prevention Techniques Abstinence Violation Effect Refers to the guilt and perceived loss of control that a person feels after a slip. Based on reaction, client returns to behaviors. Based on all-or-nothing thinking Lapse vs. Relapse (Marlatt, 1985)
Interventions to Promote Recovery Refers to choices made during slips that appear benign, but really contribute to relapse. (Marlatt, 1985) Relapse Prevention Techniques Apparently Irrelevant Decisions Making a choice to buy some cookies just to have in the house for the kids. Making a decision to stop by the rec center to see if a friend is there. Changing your snack choice to ice cream at the last minute.
Interventions to Promote Recovery Relapse Prevention Techniques Refers to thoughts, behaviors, and emotions utilized to cope with risk factors or avoid lapse Helps to avoid problematic behaviors Not giving up on self when triggered or activated Managing emotions and coping using skills that are positive (Marlatt, 1985) Adaptive Coping Responses
Interventions to Promote Recovery Relapse Prevention Techniques Window of Tolerance Clients with eating disorders often have a narrow Window of Tolerance They are unable to tolerate emotions outside of the window They utilize food-related behaviors to regulate their window Clients learn coping skills to widen the Window of Tolerance and to decrease emotions to a tolerable level without food (Ogden, 2006)
Interventions to Promote Recovery Strengths-Focused Activities Have Clients Take VIA Strengths Survey (www.authentichappiness.sas.upenn.edu) Explore Results with Client Individually or in Group -- Do results match your perception? -- What ways can you access one of your 5 top strengths in recovery? -- What are examples of ways you have used one of your top 5 strengths in your life? (Seligman, 2011)
Interventions to Promote Recovery Future-Minded Exercises Individuals Who Can Connect More to Their Future Selves May See Future Goals as More Attainable Future-Minded Activities -- Letter to Future Self -- One Hundred Things to Do in My Lifetime (Hershfield, 2011; Miller, 2005; Wilson, 2014)
Interventions to Promote Recovery Future-Minded Exercises Future Self-Imagery Clients Are Encouraged to Imagine Their Best Possible Selves for at Least 5 Minutes Each Day -- Personal, professional, and relational domains Linked to Improvements in Positive Emotion, Hopefulness, and Optimism (Lyubomirsky, 2008; Meevissen et al., 2011)
Interventions to Promote Recovery Future-Minded Exercises Letter to My Future Self Write a Letter to Future Self and Either Keep to Open or Use www.futureme.org Website to Send in the Future (Hershfield, 2011)
Interventions to Promote Recovery Future-Minded Exercises One Hundred Things to Do in My Lifetime Create a List or a Vision Board (Miller, 2005) http://carolinemiller.com/files/100_things_to_do.pdf
Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders Nicole Siegfried, PhD, CEDS nicole.siegfried@castlewoodtc.com 205-552-0417