Paper read at Eating Disorders Alpbach 2016, The 24nd … · • Momentary self-criticism, self-control, self-neglect • Eating-related situations • Other stresses (work deadline,

GJB-ICAT-BN Alpbach 2016

Paper read at Eating Disorders Alpbach 2016,

The 24nd International Conference,

October 20-22, 2016

Integrative Cognitive-Affective Therapy (ICAT)

Workshop for Eating Disorders

Gerard J. Butcher MSc.,

Cognitive Behavioural Psychotherapist,

Cognitive Solutions Clinic,

Dublin, Ireland.

[email protected]

CORE MESSAGE

• Intense negative emotional states figure prominently in the occurrence of individual episodes of bulimic behaviour. (Wonderlich et al, 2015:33)

• Intentional targeting of these emotional states is central to treatment using Integrative Cognitive Affective Therapy (ICAT)

• CRUCIALLY – it is the MOMENTARY experience of emotions that has clinical significance in the treatment of bulimia nervosa


Outline Workshop

• What is Integrative Cognitive-Affective Therapy (ICAT-BN)?

• Role of emotion in eating disorders

• ICAT model of onset and maintenance of bulimia nervosa

• Structure of treatment, goals and strategies

• Comparison with CBT


Background

• Over recent years - substantial consolidation and development of evidence-based psychological therapies for eating disorders.

• Specific forms of CBT (focused and broad), IPT, DBT, and family-based treatment have consolidated and extended their positions as treatments of choice.

• Significant need for further development of appropriate treatments (Waller 2016)


What's Effective for Eating Disorders?

• Waller (2016:3) - There re ai s the possi ilit that the le el of structure in a therapy is key to good outcomes, perhaps as much as the o te t.

• Nutritional changes appear to be necessary for psychotherapies to be effective for eating disorders.

• Co ludes … so e e ide e that other therapies for or al-weight cases can be as effective as CBT


Integrative Cognitive-Affective Therapy (ICAT)

• Short-term structured psychological treatment for Bulimia Nervosa (BN)

• Minimum 21 sessions; approx 45-50 minutes per session

• Based on models of conditioning and learning

• Retains key components (e.g., self-monitoring and prescribed eating patterns) of previously established evidence-based treatments, particularly CBT-E

• Ho e er, ICAT de eloped to spe ifi all target o e tar precipitants of eating disorder symptoms - identified as potential maintenance factors in previous empirical studies.


ICAT for Eating Disorders

• A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioural therapy (CBT-E) for bulimia nervosa. (Wonderlich et al, 2014)

• Conclusion: ICAT-BN was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E.


ICAT-BN Summary

• Evolved over 20 years as an intervention for Bulimia Nervosa

• Improve awareness and tolerance of emotional experience

• Formulate a well-structured plan to modify eating behaviour

• Develop skills to reduce likelihood of rash, impulsive behaviours (context – negative emotion)

• Identify cues for emotional experiences

• Modify source of increased negative emotions or decreased positive emotions



4 Phases of ICAT-BN Treatment

1. Phase 1: introduction and motivation

2. Phase 2: nutritional rehabilitation

3. Phase 3: identifies patterns (interpersonal and intrapersonal precipitants of negative emotions that contribute to eating disorder behaviours); self-directed styles; self-discrepancy

4. Phase 4: relapse prevention.


Cor ersto es of ICAT

Importance of emotion and interpersonal behaviour

Incorporates interventions to enhance motivation for treatment

Develops specific skills and strategies for increased awareness and

a age e t of o e tar e otio al states, i terperso al relationships and self-discrepancy

Context of robust therapeutic alliance


Treatment Contraindications

• Medical instability, suicidal ideation or behaviours – Need to be stabilized prior to commencing therapy

• Severe major depression (eg, psychosocial functioning is impaired and individual cannot engage in outpatient treatment)

• Substance use disorder – Individuals recurrently intoxicated may be unable to perform the work that is required

• Psychosis – Psychotic patients are not candidates for most psychotherapies (concurrent bulimia nervosa and psychosis is rare)

• Major life events or crises – Distracting events can interfere therapy

• Competing commitments – The inability to attend sessions disrupts therapeutic momentum

Normal Life Experiences

• Criticism, social comparison, rejection, loss

• Interact with temperamental predispositions

• Produce mental representations of the self and others that are strongly associated with emotional states

• Organise and guide future interpersonal perceptions and behaviour.


Effective Emotion Regulation (Gratz and Roemer, 2004)

1. Emotional awareness, clarity and acceptance

2. Flexible adaptive strategies to modulate intensity of emotion

3. Resist impulsive behaviours; maintain ability to engage in goal-directed behaviours (in the context of emotional distress)

4. A willingness to experience emotional distress while pursuing meaningful activities


Emotion Regulation in Life

• Negative emotion does not predict psychopathology

• I di idual s a ilit to respo d a d regulate u derl i g e otio s is crucial

• With EFFECTIVE emotion regulation, negative emotions are NOT controlled – accepted as part of normal emotional experience and tendency to control or regulate potential maladaptive behaviours

• EXERCISE: Identify personal experiences of effective emotion regulation


Role of Emotion in Bulimia Nervosa

• Wonderlich et al (2015) – participants reported on eating disorder behaviours and experiences in 'real time' in their environment

• Connection between the experience of emotion and bulimic behaviour – complicated connection; was negative emotion truly antecedent or a 'post-hoc' explanation for the bulimic behaviours?

• Initially led to education about emotional states and how to manage emotions effectively


What they didn't realise?

• "In the moments and hours before binge eating and purge behavior

occurred,negative affect was rising and positive affect was

decreasing." Wonderlich et al (2015:5)

• Important shift in focus from simply helping patients improve general emotional functioning to assisting them in identifying and managing emotions in the moments BEFORE a bulimic episode.

• Interpersonal and intrapersonal antecedents trigger emotional changes which then precipitate BN behaviour.


What about Anorexia Nervosa?

• Both Anorexia nervosa and Bulimia Nervosa are characterized by broad emotion regulation deficits, with difficulties in emotion regulation across the four dimensions found to characterize both AN and BN (Lavender et al, 2015)

• Racine et al (2013) identified multiple forms of emotion dysregulation and difficulties with impulse control in those with anorexia nervosa


Avoidance of Emotions Related to Food, Shape, and Weight

In ED, emotions related specifically to eating, shape, and weight issues are especially important. Such emotions are particularly distressing and therefore frequently avoided by individuals with BN.

Many BN behaviors function to facilitate such avoidance. Skipping meals, exercising, purging, restricting food intake, and

following rigid eating rules to help them minimize intense anxiety about weight, food, and body shape.


Conceptualising Bulimia Nervosa

• Two models inform ICAT treatment

• Onset

• Maintenance


ICAT-BN Model of Onset

• Life experiences and temperamental predispositions (harm avoidance - avoid change and situations perceived as threatening or harmful to self-esteem; negative urgency) contribute to 3 broad risk factors (interpersonal difficulties, negative self-evaluation, self-regulation deficits) for emotional difficulties.

• E otio d sregulatio + stro g thi ess ideal + e pe tatio that bulimic behaviour reduces distress = heightened risk for bulimia nervosa behaviour.


Characteristic Risk Factors for onset of BN

• Interpersonal Difficulties – historical stresses – child maltreatment, parental psychopathology (depression, substance abuse)

• Relationships within families perceived by the individual as conflicted, disengaged, non-nurturing, poor communication.

• Negative self-evaluation (high self-discrepancy, perfectionism, doubts about actions, over-concern about mistakes)


Self-Discrepancy Theory

• We arr ithi us arious do ai s of the self • The actual self - a mental representation of the attributes or features

the individual believes he/she actually possesses

• The ideal or desired self - a representation of the attributes that the individual or significant other would ideally like him/her to possess

• The ought self - a representation of the attributes that the individual or a significant other believes it is his/her obligation or duty to possess

• Related to negative mood, body dissatisfaction, body image disturbance – influences information processing



• Interpersonal Difficulties – historical stresses – child maltreatment, parental psychopathology (depression, substance abuse)

• Relationships within families perceived by the individual as conflicted, disengaged, non-nurturing, poor communication.

• Negative self-evaluation (high self-discrepancy, perfectionism, doubts about actions, over-concern about mistakes)

• Self-regulation deficits (increased self-criticism and self-control; deficits in self-acceptance, appearance, performance)



• Heightened negative emotional states

• Emotion-regulation deficits

• I ter alisatio of the thi ess ideal of Wester so iet

• Eating-related e pe ta ies ( e efits of dieti g, i ge-eating, purging behaviours)

• Belief that bulimic behaviour will reduce negative emotions


ICAT-BN Model of Maintenance

• Factors contributing to aetiology may have little to do with maintenance of BN (eg initial significance of dieting may reduce over time.

• Regardless of origins; targeting maintenance factors is most likely to produce a beneficial outcome

• Emphasis on explicit triggering situations, emotional responding and bulimic behaviours

• Brief periods of time – trigger situations elicit emotional experience and precipitates bulimic behaviour.


Momentary (Trigger) Situations

• Relationship situations

• Momentary self-discrepancy

• Momentary self-criticism, self-control, self-neglect

• Eating-related situations

• Other stresses (work deadline, financial crisis)

• All the above trigger fast increase in negative emotion and consequent decrease in positive emotion


Phases of ICAT Treatment

Phase I – (sessions 1–4; over a 1-2 week period): introduces ICAT and emphasizes motivational enhancement and the importance of emotional responding.

Phase II (6–8 sessions) nutritional rehabilitation with direct emphasis on modifying eating behaviour, facilitated by structured meal planning and coping skills.

Phase III (11-12 sessions) focuses on: identifying and modifying precipitants of negative emotional states; addresses interpersonal, self-evaluation and self-regulation problems; food- and eating-related triggers of negative emotions

Phase IV (final 2-3 sessions) emphasizes relapse prevention and healthy lifestyle planning, along with termination


Treatment Goals

• Reduce use of bulimic behaviours in high-risk moments

• Enhance emotion-regulation skills to manage situations that trigger emotion dysregulation and drive bulimic behaviours


ICAT – Core Skills phased in during therapy • Phase I - Emotion identification - FEEL skill (focus, experience, examine, and

label)

• Phase II - Meal planning – CARE skill (calmly arrange regular eating);

• ACT skill (Adaptive Coping Technique) to manage bulimic urges;

• GOAL skill (Goals, Objectives, Affect, Lifestyle)

• Phase III – Modify responses to situational and emotional cues.

• Making SEA changes (Situations, Emotions, Actions)

• Assertiveness – SAID (sensitively assert ideas and desires)

• REAL skill (Realistic Expectations Affect Living); monitor and alter negative self-standards

• Self-regulation - SPA skill (self-protect and accept)

• Phase IV - Impulse control - WAIT skill (watch all impulses today)


ICAT Core Skills; what they are, what they are not!

• Portable strategies for managing moments in time

• Teaching these skills by themselves does NOT constitute ICAT-BN therapy

• Importance of creating and establishing strong therapeutic alliance.


Phase I - Motivation Enhancement and Introducing Emotions

1. Establish a treatment relationship that clearly includes the patient as a significant collaborator in the process.

2. Enhance motivation by noting discrepancies between the effects of the ED symptoms and broader life goals.

3. “ide ith the disorder i ter s of a k o ledgi g possi le benefits of the symptoms.

4. Remain sensitive to client emotional state and make efforts to identify emotional reactions (basic strategy that is employed throughout the therapy).

5. Introduce FEEL skill (focus, experience, examine, label) 6. Begin self-monitoring of food intake.


The FEEL Skill

FEEL skill—focus, experience, examine, and label— helps gain a greater understanding of underlying emotions.

Basic education provided about emotional functioning - emotion is assumed to be a normal process that indicates that something of significance is occurring.

Also, emphasis placed on the somatic experience of emotions and attempting to use bodily cues to detect emotional experiences.

Fi all , e phasis pla ed o a tio dispositio s, hi h are the t pes of behavioral choices typically made in response to negative emotions.

All elements emphasized throughout the treatment, and clients are encouraged to practice the FEEL skill twice a day during Phases I and II.


Phase II - Meal Planning, Feelings, Adaptive Coping and Goal Setting 1. Continue self-monitoring food intake.

2. Implement formal meal planning with an emphasis on nutritionally adequate meals and snacks.

3. Introduce CARE skill (calmly arrange regular eating) and continue to practice FEEL skill within and outside of session.

4. Develop adaptive coping strategies for urge control; actively teach coping skills for purpose of assisting meal planning using ACT skill (Adaptive Coping Technique)

5. Introduce goal setting (GOAL skill; Goals, Objectives, Affect, Life moments)

6. Remain sensitive to client emotional states and make effort to identify emotional reactions and context.


The CARE Skill

1. All eating should be planned. 2. Clients should spend time each day devising their CARE plan for

the next day. 3. Clients should plan to have no more than 2–3 hours elapse

between a meal or snack. 4. Bulimic episodes are likely to continue as the CARE plan is evolving

and should be recorded so that the clinician and client can identify antecedents for these behaviors.

5. In the early stages, the variety of food is less important than the frequency and overall amount eaten.


Phase II – Therapeutic Points

It is important for the clinician and client to review meal plans and food logs at the beginning of each session.

The early Phase II session should focus almost exclusively on reviewing the CARE plans and food records, with considerable attention paid to the precipitants of problematic eating or episodes of restriction.

Deal with particular high-risk situations as they are modifying their eating pattern and planning their meals.


Phase III: Interpersonal Patterns and Problems, Self-Discrepancy and Self-Regulation

1. Initial formulation and collaborative decision about behavioural target for Phase III

2. Determine if relationship problems are present and recurrent

3. Identify the connection between emotion, interpersonal patterns, and self-directed styles and how these relate to bulimic symptoms (use of SEA change diary – situations, emotions, actions – to identify situations that trigger bulimic episodes)

4. Address role that self-evaluation may play in bulimic behavior.

5. Continue meal-planning, food monitoring and use of previous skills


Phase III Interventions

Clients are given feedback about what appears to be their typical interpersonal and self-directed style patterns. An agreement is sought to target a particular interpersonal or self-directed style that seems relevant to the ED behaviour.

Clinician modeling of patterns and role plays in session may be useful in terms of modifying interpersonal patterns.

Changing self-dire ted st les t pi all e essitates a fo us o the lie t s self-discrepancy between perceived actual self and desired self, including extreme and unattainable personal standards.

Interventions can focus on reducing perfectionist standards and acknowledgment of disavowed, but potentially valuable, aspects of the actual self.

As discrepancy is clarified, ICAT promotes a greater level of self-acceptance and pursuit of more reasonable standards


Phase III Core Skills

Clients are encouraged to monitor feeling states and consider action alternatives.

Additionally, as ICAT focuses on interpersonal patterns and self-directed styles, the SAID (sensitively assert ideas and desires) and SPA (self-protect and accept) skills are increasingly emphasized as mnemonic strategies for encouraging assertiveness, self-acceptance, and self-protection.

Finally, the REAL skill (Realistic Expectations Affect Living) is utilised to monitor and alter negative self-standards.


Phase III: Interpersonal Patterns and Self-Directed Styles – Strategies and Interventions • Strategy: Conduct interpersonal pattern and self-directed style analysis • Intervention: Identify interpersonal patterns of patient and specific

others as well as self-directed style

• Strategy: Conduct historical analysis of patterns (optional) • Intervention: Attempt to identify historical factors associated with

underlying beliefs and interpersonal rules that inform and direct the interpersonal pattern (optional)

• Strategy: Focus on changing interpersonal patterns and self-directed styles

• Intervention: Carefully elicit and clarify affect in interpersonal situations


Identifying Repetitive Interpersonal Patterns and Self-Directed Styles.

• Focus on social situations that are either closely linked in time to

ED behaviour or to significant emotional distress, as noted in food

logs; an explicit interpersonal transaction log can also be used.

• Monitor and record interpersonal transactions on a regular basis.

• Carefully assesses the transaction in terms of who was involved,

what was said or done, what was the emotional experience, and if

there was any ED behavior that may be linked in some way to the

transaction.


Structural Analysis of Social Behaviour

Used to fa ilitate ide tifi atio of repetiti e patter s or self-dire ted st les - patterns of behavior directed toward the self, so these patterns become a primary target in the modification of social behavior in ED clients.

Self-directed styles include attributes such as self-control, self-acceptance, self-protection, self-blame, and self-attack.

Attempt to understand the transaction from client perspective, including the perception of the other person (e.g., attacking, blaming, controlling, protecting, affirming, ignoring) and the perception of the client (e.g., defending, walling off, submitting, expressing)


Phase IV - Relapse Prevention and Treatment Termination

1. Construct healthy lifestyle plan.

2. Review progress in treatment and identify skills that have been particularly helpful.

3. Develop written relapse-prevention plan

4. Educate about relapse – promote vigilance and coping perspective for slip a age e t.

5. Introduce WAIT skill (Watch all impulses today)

6. Address emotions related to termination.


“o hat s differe t a out ICAT-BN?

• Greater emphasis on integration of interpersonal problems, self-evaluation, self-regulation, emotional experience.

• Momentary behavioural and emotional processes

• Relevance of contemporary emotion theories and application to understanding eating disorder behaviour

• What s the sa e? - Intensive opening phase of CBT that encourages self-monitoring and disrupts dieting behaviours.


Differences between CBT and ICAT?

• CBT - limited view of emotional responding

• CBT - less consideration of interpersonal factors

• CBT - creates an overemphasis on conscious controlled cognitive processing.


Final Word

• As emerging research developments increase our understanding of the onset and maintenance of eating disorders, newer treatments, such as ICAT-BN, can be developed and enable therapists and patients/clients to select the type of therapy approach most suited to their individual presentation of a disorder.


References

• Racine SE & Wildes JE (2013) Emotion dysregulation and symptoms of anorexia: the unique roles of lack of awareness and impulse control difficulties when upset. International Journal of Eating Disorders Nov. 46(7):713-20

• Waller G. (2016) Recent advances in psychological therapies for eating disorders. F1000 Research:702 (http://f1000research.com/articles/5-702/v1)

• Wonderlich SA, Peterson CB, Crosby RD, Smith TL, Klein MH, Mitchell JE, Crow SJ (2014). A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological Medicine Feb;44(3):543-53.


Documents

Paper read at Eating Disorders Alpbach 2016, The 24nd … · • Momentary self-criticism, self-control, self-neglect • Eating-related situations • Other stresses (work deadline,