Keeping Your Tools Sharp: Maintaining Recovery in Eating ... · Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders Nicole Siegfried, PhD, CEDS Clinical Director, The

Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders

Nicole Siegfried, PhD, CEDS Clinical Director, The Highlands

Adjunct Associate Professor, UAB

Rethinking Family Therapy in ED Treatment: Strengthening the Self Through Building the Capacity to Relate

Jim Gerber, Ph.D. Clinical Director

Locations: St. Louis, MO//Pacific Grove, CA//Birmingham, AL

2 2

● Defining Recovery

● Relapse and Recovery in Eating Disorders (EDs)

● Interventions to Promote Recovery

● Questions and Comments

Overview

• Definitions of Recovery

– Remission?

– In Recovery?

– Recovering?

– Recovered?

• Definitions of Relapse

– Relapse?

– Slip?

– Lapse?

Defining Recovery

Defining 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)

Full Recovery vs. Partial Recovery

“I just live my new life without

much thought to my 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.”

“She has an absolutely

ordinary relationship with

food.” (from a mother)

“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)

“The eating disorder feels

far away, like a distant

dream, very separate from

my current life”

Defining Recovery

IN RECOVERY FULLY RECOVERED

Fearful of relapse Confident in recovery

Vulnerable to major events Proactive to events

Accept body (still dislike) Love and accept body

Focus on ED Recovery Focus on Life

Attempting to Connect Connections

Moments of Joy and Peace Joy and Peace

Identity = ED True Identity

Defining Recovery

(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)


• 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)

Recovery Boosters


• 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)

Risks for Relapse

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

Relapse and Recovery in EDs Top 10 Relapse Triggers

Interventions to Promote Recovery

DBT Techniques Behavior Chain Analysis

• Identify the problem

behavior in detail

• Identify the

prompting event –

external trigger

• Identify vulnerability

factors-internal &

external factors that

make client

susceptible

• Identify links-specific

thoughts, actions,

sensations & feelings

• Identify

consequences

(positive & negative)

• Identify new skillful

solutions

• Identify ways to

reduce risk in future


Vulnerability Prompting Event

Thoughts

Emotions Problem Behavior

Consequence

Consequence

Consequence

Body Sensations

DBT Techniques Behavior Chain Analysis


BINGEING BEHAVIOR CHAIN

• On front:

• Write urge/behavior

• Write function of urge/behavior

• On back:

• Write affirmation

• Write coping skill(s) specific to that

urge/behavior


DBT Techniques Urge Cards

• 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/)


DBT Techniques Urge Surfing

• Encourages clients to find alternate

ways to rebel against the restrictions

and deprivations of their lives without

life-threatening behaviors, therapy-

interfering behaviors, and quality-of-life

Interfering behaviors.

Marlatt & Gordon, 1985


DBT Techniques Alternate Rebellion

Relapse Prevention Techniques Three Circles


Carnes, 2006

Attending aftercare groups and therapy appointments

Going to classes

Allowing my dietitian to be in charge

of my weight

Being honest with

others

Daily meditation

Following my meal plan

Following my exercise

plan

Skipping even one class

Coming up with excuse

not to go with

friends

Skipping a meal

Skimping on a meal or snack

Weighing myself

Staying up past 1:00AM

Running on a treadmill

Going to a gym

Committing to do two things at same time

Bingeing

Purging Exercising

when I have an injury

Trying to lose weight

lying about my food/eating Taking

diet pills

Losing weight

Walking as exercise

Going out to eat at least 1X/week

Volunteering at Habitat at least

1X/month

Taking a bubble bath at least

1X/week

Having playtime with my dogs on a daily basis

Abstinence Violation Effect

(Marlatt, 1985)

• 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

Relapse Prevention Techniques


(Marlatt, 1985)

• Refers to choices made during slips that

appear benign, but really contribute to relapse.

– 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.



Apparently Irrelevant Decisions

(Marlatt, 1985)

• 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



Adaptive Coping Responses

• 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



Window of Tolerance

(Ogden, 2006)


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)

Future-Minded Exercises

Individuals Who Can Connect More to Their

Future Selves May See Future Goals as More

Attainable

●

(Hershfield, 2011; Miller, 2005; Wilson, 2014)

Future-Minded Activities

-- Letter to Future Self

-- One Hundred Things to Do in My Lifetime

●




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)

Future Self-Imagery

(Hershfield, 2011)

Write a Letter to Future Self and Either Keep

to Open or Use www.futureme.org Website to

Send in the Future

●

Future-Minded Exercises Letter to My Future Self


(Miller, 2005)

Create a List or a Vision Board ●


http://carolinemiller.com/files/100_things_to_do.pdf


One Hundred Things to Do in My Lifetime

Nicole Siegfried, PhD, CEDS [email protected]

205-552-0417

Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders

Documents

Keeping Your Tools Sharp: Maintaining Recovery in Eating ... · Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders Nicole Siegfried, PhD, CEDS Clinical Director, The