perspectivesP E R S P E C T I V E S

AWord from the Editor

Clinicians in our field are challenged to integrate what is known with what is new, and we hopethese articles help on both fronts. TheWinter 2010 issue of Perspectives includes both novel andfamiliar topics. The articles on the phobic model, substance abuse, and intuitive eating provide newperspectives on these familiar areas of our work. The articles on EmotionAcceptance BehaviorTherapy andMotivational Interviewing introduce us to novel efforts for addressing eating disorderpsychopathology. The final article is a unique and subjective description of howmindfulness might beused to improve our treatment options.We hope these articles stir some thought. Please send yourideas and comments to dbunnell@renfrewcenter.com

Doug Bunnell, PhDEditor �

The 19th Annual Renfrew Conference Update & Save the DateFor the 2010 Conference Are Included In This Issue.

See Page 18 for Details.

Editor: Doug Bunnell, PhD

Assistant Editors: Jillian GonzalesMaryanne Werba

ContributorsBethany L. Helfman, PsyD& Amy Baker Dennis, PhD

Page 1

Carmen Bewell-Weiss, MA& Jacqueline Carter, PhD

Page 4

Julie Lesser, MDElke Eckert, MD& Joel Jahraus, MD

Page 6

Jennifer E. Wildes, PhD

Page 9

Evelyn Tribole, MS, RD

Page 11

Terry Nathanson, LCSW, LMT

Page 15

A Professional Journal of The Renfrew Center Foundation Winter 2010

UnderstandingThe Complex Relationshipbetween Eating Disorders and SubstanceUse DisordersBethany L. Helfman, PsyD & Amy Baker Dennis, PhD

Eating disorders (ED) co-occur withsubstance use disorders (SUD) at analarming rate. Prevalence data suggests thatroughly 50% of individuals with an ED arealso abusing drugs and/or alcohol, which ismore than five times the abuse rates seen inthe general population (The National Centeron Addiction and Substance Abuse [CASA],2003). Not only are there high rates ofsubstance abuse (SA) among women withED, women who use alcohol and drugsdemonstrate high rates of disordered eating.In particular, 30-40% of women with analcohol use disorder (AUD) and 16.3% ofwomen with SUD report a history of an ED(Blinder, Blinder & Samantha, 1998; Taylor,Peveler, & Hibbert, 1993) as compared tothe .9 to 3.5% of women found in the

general population (Hudson, Hiripi, Pope, &Kessler, 2007).

The co-occurrence of these disordersyields a complex clinical picture with highrates of mortality. In fact, a meta-analysis byHarris and Barraclough (1997) revealed thatpatients with anorexia nervosa (AN) andbulimia nervosa (BN) had higher rates ofsuicide than any other psychiatric disorder, arate 23 times greater than what is seen in thegeneral population. In a recent study of6,000 Swedish women with AN,Papadopoulos and colleagues (2009) foundthat compared with the general population,AN subjects were 19 times more likely tohave died from substance abuse (SA),primarily alcohol. Among all ED, the binge-purge subtype of anorexia nervosa (ANBP)

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is associated with the highest risk ofdeath (Bulik, et al., 2008).

Given the complicated nature of thesedisorders and the increased risk offatality, it is surprising to note thatED professionals have not routinelyintegrated SA treatment into theirparadigms nor have SA professionalsadequately incorporated ED treatmentinto their practices. It is all too commonfor clinicians to simplify these cases byfocusing merely on one aspect (theirspecialty) of the patient’s presentation.Regrettably, by narrowing one’s treatmentfocus, clinicians may inadvertentlyprolong suffering as these patientsvacillate between these two disorders.There are substantial costs andconsequences to the individual and thehealth care field that are cumulativeacross the lifespan when we fail toadequately treat these patients (Kessler, etal., 2003). It is therefore vital that clini-cians in both fields acquire knowledge ofthe other, and that treatment approachesof both specialties be incorporated andstudied.

A complicating factor in theunderstanding of this co-morbid group isthe fact that many randomized controlledtreatment trials (RCT) conducted in theED field exclude subjects with SUD fromtheir studies (Gadalla & Piran, 2007).As a result, we know of no empiricallysupported treatments for this co-morbidpopulation.

Even when evidence-based practicesare identified by researchers, considerabledifficulties remain in disseminating thoseresults to the practitioner in the field.The polarization between researchers andclinicians is particularly evident in the SAfield where, despite large federallyfunded research initiatives, publishedpractice guidelines and manualizedprotocols, a majority of traditional 12-step programs fail to offer EBT, such asbehavioral couples and family therapy(BCFT), which is available in only4% of the country’s SUD programs(Fals-Stewart & Birchler, 2001).Additionally, research indicates thataddiction is a chronic, relapsing disorderthat can be managed, but not cured.Yet inclinical practice, addiction is often treatedas if it were an acute disorder requiringcrisis intervention, and relapse is seen asa failure of treatment. These findingssuggest that treatment providers require

additional training to effectively treat theircurrent population, let alone theseco-morbid conditions.

Few treatment centers undertake theevaluation and treatment of co-morbidED and SUD. In fact, research suggeststhat a mere 21.7% of private SA centersoffer ED treatment (Roman & Johnson,2004). A study by Gordon and colleagues(2008) of 351 publicly funded addictiontreatment programs found that while halfof the programs screened for ED, only29% admitted complex ED cases. Ofthese programs, very few attempt to treatthe co-morbid ED. When treatment isattempted, the medical model of addictionis often the protocol to treat bothdisorders (Gordon, et al., 2008).

It is fair to say that few topics inmental health carry as much heateddebate as those of EBT in general andSA treatment in particular. EBT are, atthe present time, the best we have buttheir superiority has also been hotlydebated. Norcross and colleagues (2006)encapsulate this debate by stating“defining evidence, deciding whatqualifies as evidence and applying whatis privileged as evidence are complicatedmatters with deep philosophical and hugepractical consequences” (p. 7). Forexample, RCT, used to identify an EBT,rarely take into account other factors suchas clinician qualities, which have beenimplicated in determining patientoutcome. Additionally, certain treatmentslend themselves more readily to RCTmethodology (CBT for example) thanalternative approaches such as humanisticor psychodynamic.

We strongly support the use of EBTin the treatment of both ED and SUD.First, both disorders are protractedillnesses that require a significantcommitment of time and financialresources by patients and their families.Consumers should expect that clinicianswho identify themselves as “specialists”would be highly skilled and would utilizethe most efficacious treatment interven-tions available. Second, all patients andfamilies deserve access to the bestavailable treatments. RCT have repeatedlydemonstrated that EBT approaches workfar better than random approaches.These treatments are identified throughrigorous research and point to a specificpsychological approach or pharmacologicintervention that reduces or eliminates

symptoms of a particular psychiatricillness better than other forms oftreatment or no treatment at all. Onceidentified, clinical treatment manuals aredeveloped and designed to provide a clearroad map for clinicians by outlininggoals, decision points, strategies andtimelines.

While there are no data on a specificEBT for this co-morbid population, thereis an extensive body of evidence forthe use of EBT for each populationseparately.Yet significant controversyremains in the SA field between“traditionalists,” followers of the self-help and recovery movement, and the“revisionist culture,” academicresearchers interested in developingEBT for SUD (Wallace, 2009). Manyaddiction treatment programs continue totreat based on a 12-step, psychosocialmodel which is often delivered in groupsettings. However, the past decade haswitnessed an enormous emphasis on thestudy and utilization of EBT for SA.Examples of EBT for the treatment ofSA include cognitive behavioral therapy(CBT) and motivational enhancementtherapy (MET), which have beenmanualized by The National Instituteon Drug Abuse (www.drugabuse.gov)and BCFT. Additionally, severalpharmacological interventions have alsobeen approved by the FDA as adjunctivetreatments for SUD.

Researchers in the ED field, have alsoidentified the most efficacious treatmentsforAN, BN and binge eating disorder(BED). Maudsley, or family-based therapy(FBT), and ego-oriented individual therapy(EOIT) have been found effective in thetreatment of adolescentAN. Cognitivebehavioral therapies (CBT, enhanced CBTor CBT-E, and dialectic behavior therapy orDBT), and Interpersonal Therapy havedemonstrated specific clinical effectivenessin the treatment of BN and BED.To date,psychological interventions are theonly EBT for ED, however severalpsychopharmacological agents have beenfound effective in reducing targetsymptoms.

Another important issue to considerwith the ED/SA patient is how treatmentshould be delivered. In an integratedapproach, the same providers treatcomorbidities concurrently. This modelrequires a thorough understanding ofthe relationship between the co-morbid

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conditions. For example, does the EDtrigger the SA? Do they occurconcurrently? Or do they function in theservice of each other (i.e. amphetamineabuse in the service of the ED)? Integratedmodels have been proposed for SAand other psychiatric illnesses (i.e.schizophrenia, bipolar disorder) but notfor ED.

Sequential treatment, on the other hand,focuses on the most acute disorder firstand is often conducted with multipleproviders or in different locations.Differences in theoretical orientation, stafftraining, and treatment protocols can makecontinuity of care difficult. Data from theSA literature suggest that when co-morbiddiagnoses are treated concurrently andintegrated on-site, treatment retention andoutcome improve (Saxon & Calsyn, 1995;Weisner, Mertens, Tam, & Moore, 2001).

A considerable amount of cross-training between disciplines and specialistsneeds to take place in order to use an inte-grated treatment model. We have foundthat clinicians in the ED field are often notwell trained in the diagnosis or treatmentof SUD and are therefore ill-prepared totreat this co-morbid condition concurrently.They are not familiar with the philosophyor vernacular of AA/NA and do not fullycomprehend to the complexities of the12-step program. Similarly, clinicians inthe SA field are not always skilled in thetreatment of ED and other seriouspsychopathology or familiar withpsychopharmacological interventions.

Given the current chasm that existsbetween both the ED and SUD fields,we strongly encourage the researchcommunity to study this co-morbidpopulation. To date, there are no formalconnections between the ED and SAprofessional communities. Philosophicaldifferences and disagreements ontreatment approaches have interfered withour ability to effectively serve this group ofpatients. At the same time, clinicians in thefield are encouraged to adopt a perspectiveof change. Clinicians, like our patients, areoften resistant to change, preferring topractice whatever technique they knowbest whether or not it is efficacious fortheir population. It is our hope that thisarticle will energize both the ED and SAfields to strive for improved communica-tion, research, and willingness to learn andpractice evidence-based techniques with

the goal of enhanced patient outcomes. Welook forward to a time when every majornational conference on ED or SA willinclude workshops on the other specialty,and when graduate and medical schoolswill train their students on the complexitiesof co-morbid conditions. It is our hope thatcollaboration between these two fields andwell-funded research will lead to anincrease in both outpatient and inpatienttreatment centers that have the comprehen-sive expertise to alleviate the suffering ofthese patients. Finally, we recognize ourlimitations in providing the answers tomany of the problems inherent in treatingthis population. We hope that this articlestimulates thought and, ultimately,provokes action in the field.

References

Blinder, B., Blinder, M., & Samantha, V.(1998). Eating disorders and addiction.Psychiatric Times,15, 30-34.

Bulik, C., Thornton, L., Pinheiro, K.,Klump, K., Brandt, H., Crawford, S., et al.(2008). Suicide attempts in anorexianervosa. Journal of PsychosomaticMedicine, 70 (3), 378-383.

Fals-Stewart, W., & Birchler, G. (2001).A national survey of the use of couplestherapy in substance abuse treatment.Journal of Substance Abuse Treatment, 20,277-283.

Gadalla, T., & Piran, N. (2007). Co-occurrence of eating disorders and alcoholuse disorders in women: A meta analysis.Archives ofWomen’s Mental Health,10,133-140.

Gordon, S., Johnson, J., Greenfield, S.,Cohen, L., Killeen, T., & Roman, P. (2008).Assessment and treatment of co-occurringeating disorders in publicly fundedaddiction treatment programs. PsychiatricServices, 59, 1056-1059.

Harris, E., & Barraclough, B. (1997).Suicide as an outcome for mental disorders:a meta-analysis. British Journal ofPsychiatry,170, 205-228.

Hudson, J., Hiripi, E., Pope, H., & Kessler,R. (2007). The prevalence and correlates ofeating disorders in the NationalComorbidity Survey Replication. BiologicalPsychiatry, 61, 348-358.

Kessler, R., Berglund, P., Demler, O.,Jin, R., Koretz, D., Merikangas, K., et al.(2003). The epidemiology of majordepressive disorder: Results from theNational Co-morbidity Survey Replication(NCS-R). Journal of the American MedicalAssociation, 289, 3095-3105.

Lamb, S., Greenlick, M., & McCarty, D.(1998). Bridging the gap between researchand practice: Forging partnerships withcommunity-based drug and alcoholtreatment. Institute of Medicine.Washington, DC: National Academy Press.

Norcross, J., Beutler, L., Levant, R. (2006).Prologue. In Norcross, J., Beutler, L.,Levant, R. (Eds.), Evidence-based practicesin mental health. Debate and dialogue onthe fundamental questions (p. 7).Washington, DC:American PsychologicalAssociation.

Papadopoulos, F., Ekbom,A., Brandy, L.,& Eskelius, L. (2009). Excess mortality,causes of death and prognostic factors inanorexia nervosa. The British Journal ofPsychiatry, 194, 10-17.

Roman, P., & Johnson, J. (2004). Nationaltreatment center study summary report:Private treatment centers. University ofGeorgia, Institute for Behavioral Research.Athens, GA: University of Georgia.

Saxon, A., & Calsyn, D. (1995). Effects ofpsychiatric care for dual diagnosis patientstreated in a drug dependence clinic. TheAmerican Journal of Drug andAlcoholAbuse, 21 (3), 303-313.

Tavris, C. (2003). Foreword. In Lilenfeld, S.,Lynn, S., & Lohr, J. (Eds.), Science andpseudoscience in clinical psychology.NewYork: Guilford Press.

Taylor, A., Peveler, R., & Hibbert, G.(1993). Eating disorders among womenreceiving treatment for an alcohol problem.International Journal of EatingDisorders,14, 147-151.

The National Center onAddiction andSubstanceAbuse (CASA). (2003). Food forThought: Substance Abuse and EatingDisorders. NewYork: The National CenteronAddiction and SubstanceAbuse atColumbia University.

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A famous adage suggests that everyjourney begins with a single step, and thissentiment is especially pertinent to therapydirected towards changing maladaptivepatterns of thoughts and behavior.Clinicians who work with individuals witheating disorders (EDs) know well that notonly is it difficult to help patients to takethat first step, but that the next step (andthe one after that) is often just as hard.Because clients often present with markedambivalence about change, an initial steptowards seeking treatment may not actuallyresult in recovery. The client’s waxing andwaning motivation to change may not onlyhave a negative impact on recovery, but itcan also lead to frustration on the part ofthe clinician. Thus, as Geller and Drab(1999) have suggested, the “mismatchbetween treatment focus and clientreadiness may cause a well-intentionedtherapy to deteriorate into an entrenchedbattle between therapist and client overfood and weight” (p. 260). It is crucialthen to not only be aware of clients’intentions and motivation to recover fromtheir eating disorder at all points in thetreatment process, but also to activelyincrease that intention whenever possible.

Motivational Interviewing

Motivational Interviewing (MI) is a non-judgmental, client-focused style of therapy,where the goal is to increase the client’sintrinsic motivation to change by maxi-mizing the client’s sense of autonomy andsense of responsibility for his or herhealth. It is a therapeutic approach

designed to resolve ambivalence andfacilitate readiness to change and maytherefore be a particularly effectiveaddition to the treatment of eatingdisorders. MI (Miller & Rollnick, 2002)was originally designed from within thefield of addictions to help enhancemotivation to recover from substance usedisorders. Its aim is to explore and resolveambivalence about change by helpingclients acknowledge both the pros andcons of change by normalizing theexperience of ambivalence, and by helpingthe client situate his/her behavior withinthe context of his/her values and goals.Importantly, the interaction between thetherapist and the client is considered tobe as important a determinant of theindividual’s motivation to change as issomething intrinsic within the clienthim/herself. Thus, rather thanconceptualizing resistance as a clientcharacteristic, in MI, resistance is seen asan indication of a mismatch between thetherapeutic intervention and the client’sreadiness to change. Resistance on the partof the client is viewed as a useful warningto the therapist to switch strategies—to validate the client’s concerns aboutmaking changes, rather than pushing forbehavioral change, as this would likely bemet with more resistance.

MI facilitates a movement towardsbehavior change by encouraging the clientto put the pros and cons of change in thecontext of his/her values and goals. Bydoing so, the client may conclude that theproblematic behaviors are not, in fact,meeting his/her goals, and s/he may be

more likely to abandon these ineffectivebehaviors and look for other ways toachieve these goals. MI is not anon-directive approach, as the therapist hasa clear intention about where s/he wouldlike the client to end up, and tries toamplify the client’s reasons for changewhen possible. However, the intent is forthe client to become an advocate forchange, which allows him/her to choosethe strategies employed to achieve thechange goals, and enables the client to takeownership of the changes that s/he hasmade. In so doing, the value of the changeprocess may be increased—past researchhas demonstrated that behavior changeattributable to internal sources (driven byintrinsic motivation) occurs more often andis longer-lasting than behavior changeattributable to an external source (Geller,Drab-Hudson, Whisenhunt, &Srikameswaran, 2004). As Miller andRollnick (2002) argue, people are “morepersuaded by what they hear themselvessay than by what other people tell them.”Allowing the client to advocate for changemay also minimize power strugglesbetween the client and therapist, becausethe therapist no longer needs to argue withthe client or convince him/her to change.Thus, MI may be helpful in promoting apositive therapeutic alliance, which hasbeen shown to be not only particularlydifficult to maintain in ED treatment, butalso an important predictor of treatmentoutcome (Constantino, Arnow, Blasey, &Agras, 2005).

Weisner, C., Mertens, J., Tam, T., & Moore,C. (2001). Factors affecting the initiation ofsubstance abuse treatment in managed care.Addiction,96 (5), 705-716.

Bethany Helfman, PsyD,is a licensed ClinicalPsychologist in Michiganand NewYork. She is anindependent practitionerat Dennis & Moye &Associates in BloomfieldHills, MI where she

specializes in the treatment of adolescents,adults and families affected by eatingdisorders and their comorbidities.

In addition to her clinical practice,Dr. Helfman supervises other professionalsin the field, writes, and lectures locally inan effort to advocate for change related tothe societal factors that make recoveryfrom mental illness more difficult.

Amy Baker Dennis, PhD,has been in clinical prac-tice for over 35 years, andhas specialized in thetreatment of eating disor-ders since 1977. She hasserved as ExecutiveDirector of the National

Anorexic Aid Society (NAAS), was the

founding board president of EatingDisorder Awareness and Prevention(EDAP) and currently serves on the Boardof NEDA. As a certified cognitive thera-pist, she has designed and implementedmultidimensional treatment programs forindividuals with eating disorders andplanned and executed numerous nationaland international conferences for eatingdisorder treatment providers andresearchers. Dr. Dennis has maintained aprivate practice in Bloomfield Hills, MIsince 1988 and has taught at Wayne StateUniversity, University of South Florida,and Rollins College in Orlando, FL.

Motivational Interviewing in theTreatment of Eating DisordersCarmen Bewell-Weiss, MA & Jacqueline Carter, PhD

AMotivational Interviewing Prelude toIntensive Eating Disorder Treatment

Our group at Toronto General HospitalandYork University in Toronto recentlyconducted a study evaluating the clinicalefficacy of a brief MI interventiondelivered to a transdiagnostic sample ofpatients on the waitlist for either inpatientor day hospital treatment at the EatingDisorders Program at the Toronto GeneralHospital. Participants were randomized toeither four sessions of individual MI ora waiting list control condition. A semi-structured MI treatment manual wasdeveloped by the first author. The manualprovides suggestions for how to introducethe MI treatment and explore the client’shistory and current symptomatology usingMI principles. A distinction is madebetween two phases of MI treatment—exploring ambivalence and preparing forchange. The first phase is appropriate forclients with marked ambivalence, andincludes techniques aimed at allowing theclient to identify both the pros and cons ofchanging. In this phase, a number of MItechniques are outlined:

• Decisional Balance to identify thepros and cons of both changing andstaying the same.

• Writing a Letter to the EatingDisorder as a Friend/Enemy toidentify the costs and benefits ofchanging and beginning to connectwith the emotions involved in change.

• Identifying the Client’s Values todetermine whether there arediscrepancies between the client’scurrent actions and what is importantto him/her.

• Looking Forward ask the client todescribe potential future scenarios ifs/he decided to change or if s/hecontinued with the disordered eatingbehavior.

• Looking Backward ask the client todescribe life before the eatingdisorder.

• Importance and Confidence Rulerused throughout treatment to quantifythe client’s motivation to change andbelief in his/her ability to change.

Only after the client begins todemonstrate clear resolution ofambivalence and expresses a willingness tomove towards change should the secondphase strategies be employed. This phase isaimed at preparing for and supporting the

client through actual change. Thus, oneimportant technique in this phase is thecreation of a detailed treatment plan(clearly outlining the client’s reasons anddesires for change, and what s/he will do tobring about the change). Just as importantin this phase is to increase the client’sbelief in his/her ability to change byexploring personality traits that the clientpossesses that will be useful in changing.Clients with eating disorders often have agreat number of positive personality traits,not the least of which is extremely strongwillpower, that have allowed them toengage in behaviors that the generalpopulation would typically avoid (i.e.dieting to an extremely low weight,engaging in purging behaviors, etc.).It is important for the therapist to bringthese abilities to the client’s attention andbrainstorm the ways in which they may bemaximized so that change can be realized.Doing so may also demonstrate to theclient that s/he do not have to lose theimportant part of themselves thatdistinguishes them from others; they justneed to change the behaviors that they useto display these character traits. Thus, inthe second phase, the client and therapistwork together to build the client’sconfidence in his/her ability to changeand outline exactly how that change canbe realized.

The treatment manual was created in aneffort to facilitate measurement of theeffectiveness of MI in the treatment ofeating disorders, and outlines not only thetechniques involved in MI, but also asuggested order in which the techniquescould be implemented. However, the basicphilosophy of MI (i.e. following the client)runs somewhat counter to these efforts.Thus, throughout the treatment manual,therapists are encouraged to follow thetechniques insofar as they suit the needs ofthe particular client, and, when in doubtabout the next action, let the client guidethe choice of technique, rather than simplyfollowing the next step in the manual.

Preliminary results showed thatparticipants in the MI condition weremore likely to successfully complete thesubsequent intensive treatment program thanthose in the treatment-as-usual condition(Bewell-Weiss, Mills,Westra, & Carter,2009). In fact, with each additional sessionof MI, patients had almost double the chanceof completing the later treatment program.The MI condition was not particularly timeconsuming on the part of either the

therapist or the participant, and whenparticipants were asked informally what theythought of the sessions, their responses werevery positive about the experience. Thus, itseems that including an MI intervention maybe an especially useful and economicaladdition to an intensive, hospital-basedtreatment program.

Treatment Implications and Conclusions

Eating disorders are associated withsignificant costs and consequences. Theindividual suffering with the disorder is atsignificant risk of health problems thatcan lead to death, s/he can lose socialrelationships, may not be able to pursueoccupational goals, and often suffersfrom various co-morbid psychologicalsymptomatology associated with, andpotentially caused, by his/her eatingbehavior. In addition, treating EDs isextremely expensive and patients withanorexia nervosa who are discharged whilestill underweight have been shown to havehigher rates of rehospitalization and higherlevels of symptoms at follow-up than thosewho completed treatment programs withweights in the healthy range (Baran,Weltzin, & Kaye, 1995; Lock & Litt,2003). With such significant costs,successful intensive treatment completionis of the utmost importance. The results ofthe present study suggest that a short pre-treatment of MI is not only reasonablyinexpensive to offer and agreeable to boththe clinician and the patient, but it is alsoassociated with better subsequent treatmentoutcome, which may have significant valuefrom both the perspective of the well-beingof the client and from a health economicsstandpoint.

References

Baran, S.A., Weltzin, T.E., & Kaye,W.H.(1995). Low discharge weight and outcomein anorexia nervosa. American Journal ofPsychiatry, 152, 1070-1072.

Bewell-Weiss, C., Mills, J., Westra, H., &Carter, J. (2009). Motivational interviewingas a prelude to intensive eating disordertreatment. Presented at the annual meetingof the Eating Disorders Research Society,Brooklyn, NY, September.

Constantino, M.J., Arnow, B.A., Blasey, C.,&Agras, W.S. (2005). The associationbetween patient characteristics and thetherapeutic alliance in cognitive-behavioral

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and interpersonal therapy for bulimianervosa. Journal of Consulting and ClinicalPsychology, 73, 203-211.

Geller, J., & Drab, D.L. (1999). Thereadiness and motivation interview:Asymptom-specific measure of readiness forchange in the eating disorders. EuropeanEating Disorders Review, 7, 259-278.

Geller, J., Drab-Hudson, D.L., Whisenhunt,B.L., & Srikameswaran, S. (2004).Readiness to change dietary restrictionpredicts outcomes in the eating disorders.Eating Disorders, 12, 209-224.

Lock, J., & Litt, I. (2003). What predictsmaintenance of weight for adolescents

medically hospitalized for anorexianervosa? Eating Disorders, 11, 1-7.

Miller, W.R., & Rollnick, S. (2002).Motivational interviewing: Preparingpeople to change addictive behavior (2nded.). NewYork: Guilford Press.

Carmen Bewell-WeissMA, is in the final year ofher PhD in ClinicalPsychology at YorkUniversity in Toronto,Canada. She has workedin the Eating DisordersUnit at Toronto General

Hospital since 2004, and she is currently

completing her pre-doctoral internship atthe Centre for Addiction and MentalHealth in Toronto, Canada.

Jacqueline Carter, PhD, CPsych, hasbeen Staff Psychologist with the EatingDisorders Program at Toronto GeneralHospital in Toronto, Canada since 1997.She is also Associate Professor ofPsychiatry at the University of Toronto.Dr. Carter has published extensively in thefield of eating disorders, and she also runsa private practice treating individuals witheating disorders.

Eating Disorders –Dangers and PhobiasJulie Lesser, MD, Elke Eckert, MD & Joel Jahraus, MD

The complications of eating disorders arewell-recognized, including physical andbehavioral changes (Devlin, Jahraus &Dobrow, 2005; Kerem & Katzman, 2003).There is evidence that anorexia nervosapatients, particularly at very low weight,have both structural and functional brainchanges. Resting brain imaging studieshave confirmed that low weight anorecticshave enlarged ventricles and widened sulcisuggesting diffuse brain atrophy, as wellas reductions in both gray and whitematter. Neuropsychological research hasdemonstrated that cognitive dysfunction isa common feature of anorectics at lowweight, and these cognitive deficits may beassociated with brain abnormalities (Chui,Christensen, Zipursky, et al, 2009).One study found reduced dorsal cingulatecortex volume in low weight anorectics,which correlated with deficits inperceptual organization and conceptualreasoning (McCormich, Keel, Brumm, etal, 2008). Although all these alterationsappear to be at least partly reversible withweight restoration, some data suggests thatat least some of these brain changes maypersist after weight recovery and may evenbe related to severity of illness and tooutcome.

The amygdala in the temporal lobeof the brain, and more broadly the wholelimbic system, plays an important rolein fear/phobic responses. Functionalimaging studies suggest an exaggeratedfear response in anorectics. In one study,anorectics showed more anxiety and more

activation of the amygdala/limbic fearnetwork compared with healthy controlsafter viewing high calorie foods comparedwith low calorie foods (Ellison, Foong,Howard, et al, 1998), and in another studythere was more activation of the fearnetwork in anorectics compared withhealthy controls after viewing heavierimages of themselves (Seeger, Braus, Ruf,M., et al, 2002). Thus, the limbic system,particularly the amygdala,is likely involved in the high anxietyand extreme fear responses to foodand weight issues in patients witheating disorders.

Patients with all types of eatingdisorders frequently report high levelsof arousal or sensitivity, described asfeelings of disgust, connected to aspectsof body image or sensations. Theseexperiences are usually linked withcompensatory escape behaviors that aremaintained by negative reinforcement.Dietary restriction, common in eatingdisorders, is an example of an avoidancebehavior which typically occurs inresponse to specific rules and core beliefs,in some ways similar to avoidancebehaviors in other anxiety conditionssuch as obsessive compulsive disorder,agoraphobia, social phobia or specificphobia.

There are such high rates of co-morbidanxiety disorders in patients with eatingdisorders that the anxiety disorders areviewed as a vulnerability factor for theonset of eating disorders. The rates of

anxiety disorders are similar in all threesubtypes of eating disorders, AN, BN andEDNOS, with up to two thirds of patientsreporting one or more anxiety disordersduring the lifetime, with onset typicallyduring childhood. If not actually diagnosedwith an anxiety disorder, ED patients oftenhave other traits connected to anxiety suchas perfectionism and harm avoidance.Recent data from the Genetics of AnorexiaNervosa study (Dellava, Thornton, Hamer,Strober et al, 2009) show an associationbetween childhood anxiety and fearfulbehaviors with caloric restriction and lowBMI in anorexia nervosa. Atypical presen-tations of anorexia nervosa, especially inyoung children, may be associated moredirectly with specific phobias for chokingor vomiting. Malnutrition itself may beassociated with anxiety and activationof a fear response, as identified in theMinnesota starvation study (Keys, et al,1950), and a low BMI in childhood is arisk factor for the development of aneating disorder later in life.

Eating at regular intervals andgradually reintroducing feared foods iscentral to behavior change and recovery.Most treatment approaches, whether it isemphasized or not, incorporate this keyelement of exposure therapy. There isan emphasis on self-monitoring andevaluation of cognitive distortions.Successful treatments involve learningnew coping strategies and problemsolving skills to contain anxiety andprevent a return to avoidance behaviors.

Perspectives • Winter 2010 Page 7

In considering treatment interventionssuch as family-based treatment, cognitivebehavioral treatment and dialecticalbehavioral therapy for eating disorders,it is useful to consider the principles ofexposure therapy for phobias, and it isoften helpful to use this framework indiscussing the approach to treatment andin setting goals with patients and families.

Phobias are considered excessivefears, and the different types (includingsocial phobia, agoraphobia and differentcategories of specific phobia) vary inage of onset. Maintaining factors forphobias share similarities to factorswhich maintain an eating disorder.Three components maintain a phobia:the cognitive (phobic thinking andbeliefs), the behavioral (typicallyavoidance, such as more subtle formsof avoidance such as excessive relianceon safety signals, including reliance onstaff helpers and familiar routines), andthe physiological (distress responsesassociated with the feared situation orobject). Causes of phobias includegenetic factors and environmentalinfluences, with direct and indirect(vicarious or instructional) conditioning,often combined. Negative life events,negative attributional styles, and avoidantcoping strategies predict fear responses inchildren, but these are moderated by thetype of information (negative or positive)given to children. Another model focuseson non-associative fear responses, such asinnate fears found in normal development,with phobias viewed as occurring as aresult of enhanced genetic fear responsesor deficits in modulating responses.Perhaps malnutrition itself is a moderatingfactor, since, clinically, the fears andavoidant behaviors associated with eatingdisorders tend to increase as the nutritionalstate deteriorates, and to lift or improveas the malnutrition resolves.

Exposure therapy for phobias targetscognitive distortions and biases with thelearning of new, non-dangerous meanings(Craske & Barlow, 2007). Phobic thinkingtypically involves overestimates of dangerand catastrophe thoughts such as notbeing able to cope with or tolerate thefeared situation. The main interventioninvolves approaching the feared object orsituation, hence the term exposure, so thatthe individual learns that nothing bad willhappen and that he or she is able totolerate and cope with the situation.Strategies in exposure therapy include

contingency management procedures,modeling, systematic desensitizationand cognitive or self-control procedures(Craske, Antony & Barlow, 2006).One self-control procedure designed tohelp in childhood fears is called theSTOP technique, which stands forS: feeling Scared, T: having the Thoughtthat... O: some Other thought or behavior,and P: Praise (myself) for coping(Silverman & Moreno, 2005). Teachingthis technique has been helpful in ourprogram when an impasse occurs overeating specific foods, either at home or inthe hospital. Exposures are designed sothat corrective learning occurs.

Structured behavioral interventions foreating disorders on an inpatient unit ofteninclude components of exposure therapyin the milieu rules and contingenciesset up for the dining room, for gainingprivileges, and in establishing criteria fordischarge. If a patient struggles tocomplete an item planned for a meal, areplacement is offered, but the goal is tostop taking the replacements for regularfoods. When a patient continues to takeexcessive amounts of replacements,explaining the nature of avoidance andphobic thinking is typically the mosthelpful intervention. There is a higherrisk of relapse following discharge fromthe inpatient unit if a patient returns toavoidance behaviors such as avoidinghigh density foods. Patients who receive acognitive behavioral therapy interventionfollowing discharge from an inpatientunit show higher rates of recovery (Attia&Walsh, 2009). In many programs, atransition from the inpatient unit to apartial hospital or intensive outpatientprogram helps prevent a return toavoidance behaviors.

Cognitive behavioral treatmentfocuses on recognizing and changing theovervaluation of being thin, which isconnected to the fear of becoming fat oroverweight (Agras &Apple, 1997).The process of weight exposure helps theindividual begin to tolerate anxiety whilelooking at his or her weight and plottingit on a graph. The data provides a contextfor understanding trends in weight gainover time and for establishing what areconsidered healthy weight ranges(Fairburn, 2008). The patient learns thatnothing dangerous will happen to his orher weight by following a pattern ofregular eating. Patients use self-monitoring logs to evaluate typically

phobic thoughts, and homework involveschallenges such as breaking specificrules, with an emphasis on increasingreflective capacity to recognize the eatingdisorder mindset or the associatedperfectionist mindset, and using activeproblem solving strategies to confrontand change thoughts and avoidancebehaviors.

Dialectal behavior therapy has beenadapted for eating disorders with a focuson improving regulation of emotionsfor patients with co-morbid borderlinepersonality disorder, severe or complexeating disorders, and for binge eatingdisorder and bulimia nervosa(Wisniewski, Safer & Chen, 2007). Thereis an emphasis on self-monitoring, activeproblem solving, and skills training;specific targets include avoidancebehaviors, with the provision of validating(reinforcing) responses for behaviorchange. Binge eating and restricting areviewed as escape behaviors, which maybecome negatively reinforced. Exposureprotocols in dialectical behavior therapyfor eating disorders include: commitmentstrategies to prevent specific behaviors,regular eating and weighing interventions,and the use of diary cards to monitorbehaviors and use of adaptive copingskills. Coaching calls are used to helpimplement problem solving strategies,with the timing of the calls designed toreinforce changes in behavior, instead ofreinforcing avoidance or escape behaviors.

In family-based therapy, parents areplaced in charge of the regular eatingintervention (Lock, LeGrange, Agras,& Dare, 2001; LeGrange & Lock, 2007).The family receives education aboutthe risks of malnutrition and the natureof the eating disorder. There is aseparation of the illness from theindividual (e.g. “I know this is your eatingdisorder talking…”) and a focus onhelping the parents address changes andconcerns about eating. This approachemphasizes active problem solvingstrategies to minimize behavioral problemsand expressed emotion (criticism, hostilityand emotional over-involvement) (Pereira,Lock, & Oggins, 2006). The parents aretrained directly to view their role ashelpers, because negative interactions,such as a critical stance, will impedeprogress. There is an emphasis onvalidation strategies such as praise,positive reinforcement, and empathy,similar to principles of dialectical behavior.

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There is also a specific focus onconfronting behavioral avoidance, asin cognitive behavior therapy for eatingdisorders.

Given the recent findings in brainresearch confirming the activation offear centers and responses in patientswith eating disorders, therapists mayfind it particularly helpful to frametreatment more directly as an exposuretherapy intervention.

References

Agras, S.W. &Apple, R.F. (1997).Overcoming eating disorders: A cognitive-behavioral treatment for bulimia nervosaand binge eating disorder. NewYork:Oxford University Press.

Attia, E. &Walsh, T. (2009). Behavioralmanagement for anorexia nervosa. The NewEngland Journal of Medicine, 500-506.

Chui H.T., Christensen, B.K., Zipursky,R.B., Richards, B.A., Hanratty, M.K.,Kabani, N.J., Mikulis, D.J., & Katzman,D.K. (2009). Cognitive function and brainstructure in females with a history ofadolescent-onset anorexia nervosa.Pediatrics, 122, 426-437.

Craske, M.G., Antony, A.M. & Barlow,D.H. (2006).Mastering your fears andphobias: Second Edition. NewYork:Oxford University Press.

Craske, M.G. & Barlow, D.H. (2007).Mastery of your anxiety and panic:Fourth Edition. NewYork: OxfordUniversity Press.

Dellava, J.E., Thornton, L.M., Hamer, R.M.,Strober, M., et al. (2009). Childhoodanxiety associated with low BMI in womenwithAnorexia Nervosa. Behavior, Researchand Therapy, 47.

Devlin, M.J., Jahraus, J.P. & Dobrow, I.J.(2005). Eating disorders. In J.L. Levenson(Ed.), The American Psychiatric PublishingTextbook of Psychosomatic Medicine (pp.2-34). Arlington, VA:American PsychiatricPublishing, Inc.

Ellison Z., Foong, R., Howard, E., et al.(1998). Functional anatomy of calorie fearin anorexia nervosa (letter).Lancet 352, 1192.

Fairburn, C.G. (2008). Cognitive BehaviorTherapy and Eating Disorders. NewYork:Guilford Press.

Kerem, N.C. & Katzman, D.K. (2003).Brain structure and function in adolescentswith anorexia nervosa. AdolescentMedicine, 14, 109-118.

Keys, A., Brozek, J., Henschel, A.,Mickelsen, O., & Taylor, H.L. (1950).The Biology of Human Starvation(Two volumes).MN: University ofMinnesota Press.

LeGrange, D.L. & Lock, J. (2007). Treatingbulimia in adolescents: A family-basedapproach. NewYork: Guilford Press.

Lock, J., Grange, D.L., Agras, S.W. & Dare,C. (2001). Treatment manual for anorexianervosa: A family-based approach. NewYork: Guilford Press.

McCormick L.M., Keel, P.K., Brumm,M.C., Bowers, W., Swayze, V., Andersen,A., & Andreasen, N. (2008). Implicationsof starvation-induced change in right dorsalanterior cingulate volume in anorexianervosa. International Journal of EatingDisorders, 41 (7), 602-610.

Pereira, T., Lock, J. & Oggins, J. (2006).Role of therapeutic alliance in familytherapy for adolescent anorexia nervosa.International Journal of Eating Disorders.39, 677-684.Wilmington, DE:WileyPeriodicals, Inc.

Seeger, G., Braus D.F., Ruf, M., et al.(2002). Body image distortion revealsamygdala activation in patients withanorexia nervosa – a functional magneticresonance imaging study. NeuroscienceLetters, 326, 25-28.

Silverman,W.K. & Moreno, J. (2005).Specific phobia. Child andAdolescentPsychiatric Clinics of North America. 14(4), 819-843.

Wisniewski, L., Safer, D. & Chen, E.(2007). Dialectical behavior therapy andeating disorders. Dialectical BehaviorTherapy in Clinical Practice: ApplicationsAcross Disorders and Settings, 7, 174-221.

Julie Lesser, MD, special-izing in Child, Adolescentand Adult psychiatry, isLead Psychiatrist andProgram Director at thePark Nicollet MelroseInstitute. Dr. Lesser hascompleted intensive

dialectical behavior therapy training. Sheis a member of the clinical faculty of theUniversity of Minnesota Department ofPsychiatry, and is actively involved inteaching medical students and staff.

Elke Eckert, MD, is Professor ofPsychiatry at the University of Minnesotaand has been a consultant psychiatrist atthe Park Nicollet Melrose Institute for nineyears. She started the Eating DisorderProgram at the University of Minnesota inthe 1970's and has numerous publicationsin the eating disorders area, particularlyanorexia nervosa.

Joel Jahraus, MD,FAED, is currently theExecutive Director of theMelrose Institute at ParkNicollet Health Servicesin Minneapolis, MN(previously the EatingDisorders Institute). After

several years of private practice he becamethe Pre-doctoral Director at the Universityof Minnesota Medical School after whichhe became the Medical Director of theEating Disorders Institute. Dr. Jahraus hasco-authored a chapter on eating disordersin Psychosomatic Medicine, an AmericanPsychiatric Association Publishing text-book, and has been featured in variousmedia including two national publictelevision documentaries on eatingdisorders, and interviews in PeopleMagazine, The NewYork Times andEntertainment Tonight Online. He testifiedon the need for health insurance coverageat a United States Congressional Briefingon eating disorders.

Perspectives • Winter 2010 Page 9

The absence of evidence-based treatmentinterventions for older adolescents andadults with anorexia nervosa (AN) is oneof the most serious issues in the eatingdisorders field. Although family therapy hasshown promise in the treatment of youngeradolescents who have been ill for a relativelyshort time, this approach generally is notrecommended for individuals age 17 yearsand older who comprise the majority ofANpatients (Bulik, Berkman, Brownley, et al.,2007). For underweight individuals, nutritionrehabilitation aimed at normalizing eatingbehaviors and restoring a healthy bodyweight is the cornerstone of recovery.However, there is expert consensus thatnutrition rehabilitation alone is insufficientto promote lasting improvements in anorexicpsychopathology (Agras, Brandt, Bulik,et al., 2004).

Psychotherapeutic interventions thatcombine nutrition rehabilitation withsupport, psycho-education, and other activetherapeutic ingredients may hold promise inthe treatment of older adolescents and adultswithAN. Preliminary reports have suggestedthe utility of cognitive behavior therapy(CBT) in preventing relapse among weight-restoredAN patients (Carter, McFarlane,Bewell, et al., 2009; Pike,Walsh, Vitousek,et al., 2003). However, the results from onestudy indicate that CBT may not be theoptimal approach for treating underweightindividuals withAN (McIntosh, Jordan,Carter, et al., 2005). In the current U.S.care environment, fewAN patients are fullyweight-recovered at discharge from intensivetreatment programs. Moreover, manyindividuals withAN do not have access tostructured treatment settings that providenutrition rehabilitation or address eatingdisorder psychopathology. Thus, there is acritical need for the development of effectiveoutpatient interventions for underweightindividuals withAN.

EmotionAcceptance BehaviorTherapy

Emotion acceptance behavior therapy(EABT) is an outpatient psychotherapeuticintervention designed specifically for olderadolescents and adults withAN. Theprinciples of EABT derive from empirical

work on the psychopathology and treatmentofAN, clinical experience, and the generalpsychotherapy research literature. Consistentwith other recent clinical formulations ofAN (e.g. Schmidt &Treasure, 2006), EABTis based on a conceptual model that empha-sizes the role of anorexic symptoms infacilitating avoidance of aversive emotions(see Figure 1). Specifically, the EABTmodel postulates that people withAN oftenare characterized by individual features, suchas inhibited or harm avoidant personalitytraits and problems with anxiety and mooddisturbance, that shape their experience ofemotion as aversive and uncontrollable.This negative experience of emotion resultsin “emotion avoidance,” that is, the desire toavoid experiencing or expressing physicalsensations, thoughts, urges, and behaviorsrelated to emotional states. Anorexicsymptoms (e.g. extreme dietary restraint,purging, excessive exercise, ruminativethoughts about eating, shape, or weight)are hypothesized to serve the function offacilitating emotion avoidance bya) preventing patients from experiencingemotions and b) reducing the intensity andduration of emotional reactions.

The EABT model assumes thatemotion avoidance poses two mainproblems for individuals with AN. First,although AN symptoms may be effective atreducing emotions in the short term, overthe long term, efforts to avoid emotionmay have the paradoxical effect ofincreasing the frequency and intensity ofaversive emotional reactions (Moses &Barlow, 2006). Consequently, AN patientsmay become trapped in a cycle ofemotional vulnerability, avoidance, anddisordered eating. Second, because patientsspend so much time focused on ANsymptoms, valued goals in other areas oftheir lives are neglected. Thus, the primarytreatment targets in EABT are: 1) ANsymptoms, 2) emotion avoidance, and 3)disconnection from other valued activitiesand relationships.

Conducting EABT

The EABT approach to treatment combinesstandard behavioral interventions that arecentral to the clinical management ofAN(e.g. weight monitoring, prescription ofregular, nutritionally-balanced eating) with

Emotion Acceptance BehaviorTherapy:A NewTreatment forOlder Adolescents and Adults with Anorexia NervosaJennifer E.Wildes, PhD

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psychotherapeutic techniques designed toincrease emotion awareness, decreaseemotion avoidance, and encourageresumption of valued activities andrelationships outside the eating disorder.EABT is heavily influenced by what hasbeen termed the “third generation” ofbehavior therapies (Hayes, Luoma, Bond,et al., 2006), examples of which includeAcceptance and Commitment Therapy(ACT), Dialectical Behavior Therapy(DBT), and Mindfulness-Based CognitiveTherapy (MBCT). Third generationbehavior therapies are distinguished fromtraditional behavioral and cognitive-behavioral approaches by an increasedemphasis on the context and function ofpsychological phenomena. Thus, EABTfocuses on helping patients to identify thefunctions served by AN symptoms,including the connection between ANsymptoms and emotion avoidance, and toadopt alternative strategies (includingcultivating a willingness toexperience/tolerate uncomfortableemotions and other avoided experiences)in the service of reconnecting with othervalued activities and relationships.

Structure ofTreatment

EABT is a manualized, individual,outpatient psychotherapy for patients age17 years and older with AN. Sessions areoffered 1-2 times per week for a minimumof 40 weeks. Weekly treatment iscontingent on weight stabilization (i.e., noweight loss for > 2 weeks and medicallystable) and sustained improvements inother eating disorder symptoms (e.g.purging). Although individual therapysessions are the primary vehicle forchange, EABT is designed to be providedin the context of a multidisciplinary eatingdisorders treatment team. In addition tomeeting with their therapist, patientsenrolled in EABT receive weekly medicalmonitoring from a nurse or nursepractitioner and meet monthly with apsychiatrist. Patients and therapists alsoconsult with a registered dietitian forassistance with meal planning. Finally,patients and therapists may scheduleadjunctive psycho-educational orsupportive sessions that include familymembers or supportive others. However,family therapy is not a component of theEABT intervention.

SessionTopics andTherapeuticTools

EABT is divided into 3 phases; however,content across therapy sessions isoverlapping, and the phases are notintended to be distinct. All sessions includea weight and symptom check-in(conducted by the nurse), review of thepast week from the patient’s perspective,and validation of the patient’s concernsabout gaining weight and reducing eatingdisorder symptoms. Although the focus ofEABT is intended to be on issues that thepatient identifies as relevant and important(as opposed to symptom management),therapists emphasize that this focus canbe maintained only when eating disordersymptoms are at a level that does notinterfere with crucial psychological work(e.g. stable weight, normal lab values).Thus, close monitoring of eating disordersymptoms is prescribed for patients whosesymptoms are not stable with theexpectation that this focus will diminishover the course of treatment. Some patientsstruggle with the idea of stabilizingsymptoms or have difficulty reducingeating disorder behaviors. In these cases,the focus of therapy sessions turns tosymptom management and motivationenhancement, with an emphasis on helpingthe patient identify discrepancies betweenher/his eating disorder symptoms and othervalued goals and relationships. Additionaltherapeutic strategies employed duringeach phase of EABT are outlined below.

Phase 1.As in other psychotherapies,the initial sessions of EABT focus onorienting the patient to treatment andbuilding a therapeutic relationship. Amajor aim of Phase 1 is for the therapistand patient to develop a sharedunderstanding of the patient’s illness witha particular emphasis on the relationbetween eating disorder symptoms and thepatient’s experience of emotion. TheEABT model is introduced, and the patientand therapist work together to develop apersonalized model that reflects thepatient’s history, symptom functions, andvalues. At the close of Phase 1, the patientand therapist collaborate to set treatmentgoals for: 1) weight gain/reduction ofeating disorder symptoms, 2) acceptanceof emotions and other avoided experiences,and 3) participation in other valuedactivities and relationships.

Phase 2. The focus of Phase 2 ishelping the patient meet her/his treatmentgoals using psychotherapeutic techniquesadapted from third generation behaviortherapies. The patient and therapist workcollaboratively to determine the focus ofsessions and to select therapeutic tools thataddress the patient’s needs. Three of thetools employed most frequently inEABT (e.g. mindfulness exercises, self-monitoring, and graded exposure) aredescribed below. The patient’s progress inmeeting goals for weight gain/symptomreduction also is evaluated duringPhase 2 and additional goals are set,as clinically indicated.

Mindfulness exercises are used to helpthe patient observe, describe, and toleratefeelings, thoughts, and physical sensationsrelated to aversive emotional states.At the beginning of treatment, mindfulnessexercises are used to assist the patient inconnecting with the present moment by,for example, observing and describingher/his surroundings or through deepbreathing techniques. Later on,mindfulness exercises focused morespecifically on the experience of emotion(and related thoughts/physical sensations)are incorporated both in-session and asbetween-session homework.

Self-monitoring involves recordingexperiences (e.g. emotions, activities, foodintake) that occur between treatmentsessions. The purpose of self-monitoring inEABT is to help the patient identify linksbetween AN symptoms and emotionalreactions or disconnection from othervalued activities and relationships. Forexample, daily activity monitoring isused to evaluate the amount of time thepatient is spending on eating disordersymptoms versus other valued activitiesand relationships, and to set goals forincreasing participation in other valueddomains.

In graded exposure, the patient andtherapist develop a hierarchy of fearedexperiences related to a particular stimulusand develop a plan for helping the patientincrease her/his contact with these experi-ences. For example, exposure may be usedto help the patient increase willingness toenter situations that provoke aversiveemotional reactions (e.g. social settings) orto address concerns more directly relatedto disordered eating (e.g. fear of physicalsensations related to swallowing/choking).

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Phase 3. The final 4-6 sessions ofEABT focus on relapse prevention andissues related to termination. The patient’spersonalized model of AN is reviewed andupdated and plans for continuing accep-tance and value-based living are discussed.The patient and therapist also collaborateto develop a personalized plan for relapseprevention based on the course of therapy.

Summary

In summary, EABT is a new treatmentfor older adolescents and adults withAN that is based on a conceptual modelemphasizing the role of anorexicsymptoms in helping individuals avoidaversive emotional states. EABTincorporates standard behavioralinterventions that are central to theclinical management of AN withempirically-supported third generationbehavior therapy techniques that haveshown promise in the treatment of otherchronic, refractory psychiatric conditions(e.g. borderline personality disorder).Our research group has been fortunate toreceive funding from the National Instituteof Mental Health to conduct a pilot studyof EABT, and data collection is underway.The results of this study, which weanticipate will be available in early 2011,will guide our future work on thedevelopment of interventions for olderadolescents and adults with AN.

EABT was developed by Dr. Wildes andDr. Marsha Marcus at the Center forOvercoming Problem Eating at WesternPsychiatric Institute and Clinic, Universityof Pittsburgh Medical Center.

References

Agras,W.S., Brandt, H.A., & Bulik, C.M.,et al. (2004). Report of the NationalInstitutes of Health workshop onovercoming barriers to treatment research inanorexia nervosa. International Journal ofEating Disorders, 35, 509-521.

Bulik, C.M., Berkman, N.D., & Brownley,K.A., et al. (2007). Anorexia nervosatreatment: A systematic review ofrandomized controlled trials. InternationalJournal of Eating Disorders, 40, 310-320.

Carter, J.C., McFarlane, T.L., & Bewell, C.,et al. (2009). Maintenance treatment foranorexia nervosa:A comparison of cognitivebehavior therapy and treatment as usual.International Journal of Eating Disorders,42, 202-207.

Hayes, S.C., Luoma, J.B., & Bond, F.W.,et al. (2006). Acceptance and CommitmentTherapy: Model, process and outcomes.Behaviour Research andTherapy, 44, 1-25.

McIntosh, V.V.W., Jordan, J., & Carter, F.A.,et al. (2005). Three psychotherapies foranorexia nervosa:A randomized, controlledtrial. American Journal of Psychiatry, 162,741-747.

Moses, E.B. & Barlow, D.H. (2006). A newunified treatment approach for emotionaldisorders based on emotion science. CurrentDirections in Psychological Science, 15,146-150.

Pike, K.M.,Walsh, B.T., &Vitousek, K.,et al. (2003). Cognitive behavior therapy inthe posthospitalization treatment of anorexianervosa. American Journal of Psychiatry,160, 2046-2049.

Schmidt, U. &Treasure, J. (2006). Anorexianervosa: Valued and visible. A cognitive-interpersonal maintenance model and itsimplications for research and practice.British Journal of Clinical Psychology, 45,343-366.

Jennifer E.Wildes, PhD, isAssistant Professor ofPsychiatry at the Universityof Pittsburgh School ofMedicine andWesternPsychiatric Institute andClinic, University ofPittsburgh Medical Center.

Her research and clinical interests includeanorexia nervosa in adults and the intersec-tion of eating disorders with other psychi-atric and medical problems.

Intuitive Eating in theTreatment of Eating Disorders:The Journey of AttunementEvelyn Tribole, MS, RD

Patients with eating disorders are virtuallythe polar opposite of Intuitive Eaters.Intuitive Eaters possess three corecharacteristics, the ability to (Tylka, 2006):

• Eat for Physical Rather thanEmotional Reasons.

• Rely on Internal Hunger andSatiety Cues.

• Unconditional Permission to Eat.

Growing research indicates thatIntuitive Eaters eat a diversity of foods,are optimistic, have better self-esteem,and healthier body weights withoutinternalizing the thin ideal (Tribole, 2009).

What is the best way to facilitate theattunement needed to become an IntuitiveEater? This article describes when andhow to implement Intuitive Eating forpatients recovering from an eatingdisorder.

Nutrition Rehabilitation Phase I:Intuitive Eating is Contra-Indicated

“Broken Satiety Meter.”When anindividual is in the throes of an eatingdisorder, she is not capable of accuratelyhearing biological cues of hunger andfullness. In this situation, I tell mypatients, their “satiety meter” is broken, a

consequence of complex interactions ofmind-body biology and malnutrition.Chronic malnutrition results incompensatory slowing of digestion inwhich patients experience early andprolonged fullness.

Additionally, it is hard for binge eatersto recognize “gentle fullness,” whenpainful binge cycles prevail. For thebulimic patient, the sensation of fullnessis often distorted by the cessation ofpurging behaviors (such as vomiting orlaxatives), which can cause temporarybloating. Amplifying the problem is theneuro-chemical cascade triggered by stress

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and anxiety about eating issues which, inturn, may blunt hunger and cause nausea.

Nutrition Rehabilitation. In the begin-ning of treatment, nutrition rehabilitationusually requires some sort of eating plan(often under the direction of a nutritiontherapist). This is similar to when a cast isneeded to support the healing of a brokenarm. The cast provides structure andsupport, but it is not lifelong, nor thedestination in recovery. The cast is useduntil the bone is strong enough on its own.Similarly, a meal plan serves as structureand support, until there is biologicalrestoration. For a low-weight patient, thisincludes weight restoration.

Nourishment as Self-Care. The bodyhas been through nutritional trauma andneeds consistent nourishment withadequate calories. In this phase, nutritionrehabilitation is a form of necessary self-care, regardless of the absence of hungeror the presence of early fullness. Thisproscriptive eating phase is somewhatmechanical because, in this early stage, apatient’s willingness alone is usually notenough to assure adequate intake.

Boundaries:The Role of theSchedule of Eating

Creating a schedule of eating (with thepatient) helps contain “eating anxiety”by establishing a predictable expectationof when to eat. Eating regularly helpsfoster body rhythms, which includehormonal patterns that help the bodygear up for digestion.

In an outpatient setting, I like toestablish a built-in flexibility of 30 minutesfor each agreed upon eating time. Forexample, if the patient agrees to eat lunchat 12:00, then eating between 11:30 and12:30 is acceptable. But if that 30 minutesof flex-time is up, the patient needs tostop-and-drop (the other tasks at hand)and feed her body. This is an importantconcept, because it helps the patientestablish her self-care (nourishment) as anon-negotiable priority. For example, shemight need to tell her friends she must eatfirst, before shopping (rather than visaversa). This often requires learning andpracticing assertiveness skills.

During this phase, gentle hunger cuesbegin to emerge. Keep in mind that theoccurrence of regular hunger cues variesand is determined by many factorsincluding:

• Duration of eating disorder.• Severity of malnutrition.• Intensity of anxiety and fearabout eating.

• Motivation for Recovery.• Medications (which can distorthunger and satiety cues).

Phase 2: Identifying, Normalizing andResponding to Satiety Cues

It is vital that satiety cues are normalizedbefore further exploring Intuitive Eating.The challenge lies beyond “hearing” therange of physical hunger and fullness cues.Patients need to learn how to respond

appropriately to these cues when theyarise. This also means developing theability to distinguish between physicaland emotional cues.

As a person’s hunger and fullness cuesresurface, it’s not unusual for fears anddistorted beliefs to arise in-tandem. Forexample, some patients distort andmislabel the sensation of fullness as“proof ” of overeating. Consequently, theymay fear any fullness and label it as “bad”or “wrong.” Or, some patients mightbelieve that achieving fullness meanseating just until the hunger goes away, butnot a single bite more.

In this stage it is helpful to explore the

Core Principle

Reject the Diet Mentality

Honor Your Hunger

Make Peace with Food

Challenge the FoodPolice

Feel Your Fullness

Discover theSatisfaction Factor

Cope with Emotionswithout Using Food

Respect Your Body

Exercise

Honor Your Health

Anorexia Nervosa

Restricting is a core issue and canbe deadly.

Weight Restoration is essential. Themind can not function and think properly.You are likely caught in an obsessionalcycle of thinking and worrying aboutfood, and have difficulty making a deci-sion. Your body and brain need caloriesto function. Your nutrition therapist willwork with you to create a way of eatingthat feels safe to you.

Taking risks, add new foods, when ready.Do this gradually, take baby steps.

Challenge the thoughts and beliefs aboutfood. Take the morality and judgmentout of eating.

You can’t rely on your fullness signalsduring the beginning phases of recoveryas your body likely feels prematurely fulldue to slower digestion.

Frequently, there are fears or resistanceto experiencing the pleasure from eating(as well as other pleasures of life).

You may often feel emotionally shutdown. Food restriction, food rituals andobsessional thinking are the coping toolsof life. With re-nourishment, you will bemore prepared to deal with feelings thatemerge.

Heal the body image distortion.

You will likely need to stop exercising.Learn to remove the rigidity of nutrition—where there is a strict adherence to“nutritional principles”, regardless of theirsource.

Recognize that the body needs:Essential fatCarbohydratesEnergyVariety of Foods

Bulimia Nervosa/Binge Eating Disorder

Restricting does not work and triggers primalhunger, which can lead to binge eating.

Eat regularly—this means 3 meals and 2 to 3snacks. Eating regularly will help you get intouch with gentle hunger, rather than theextremes that often occur with chaotic eating.Ultimately, you will trust your own hunger signalseven if they deviate slightly from this plan.

Take risks, try “fear” foods, when ready and notvulnerable. Vulnerable includes over-hungry,overstressed, or experiencing some other feelingstate.

Challenge the thoughts and beliefs about food.Take the morality and judgment out of eating.

A transition away from experiencing the extremefullness that is experienced with binge eating.Once regular eating is established, gentle full-ness will begin to resonate. Note: if you arewithdrawing purging, especially from laxatives,you may temporarily feel bloated which willdistort the feeling of fullness.

If satisfying foods and eating experiences areincluded regularly, there will be less impetus tobinge.

Binge eating, purging, excessive exercise areused as coping mechanisms. You can begin totake a time out from these behaviors to startexperiencing and dealing with feelings.

Respect the here and now body.

Over-exercising can be a purging behavior.Moderate exercise can help manage stress andanxiety.

Learn to remove the rigidity of nutrition. There isa strict belief as to what constitutes healthyeating, and if this belief is violated, purgingconsequences can ensue (if bulimic). Recognizethat the body needs:Essential fatCarbohydratesEnergyVariety of Foods

How Intuitive Eating Principles Apply to Eating Disorders

*from Tribole, E. & Resch, E. Intuitive Eating, 2nd ed (2003). NewYork: St. Martin’s Press.

Perspectives • Winter 2010 Page 13

patient’s understanding and beliefs aroundhunger and fullness. What is the expecta-tion around satiety cues? What might“normal” cues feel like? What did thesecues feel like before the eating disorderdeveloped? What fears arise for the patientabout the idea of responding appropriatelyto hunger and fullness cues? It is alsoimportant to emphasize that there is nosingle “correct” way to experience thesebiological cues.

Dealing with “False-Labeling” of BodyCue Experiences. In general, there is athree-step process to normalizing satietycues:

1. Develop ability to identifyphysical cue.

2. Normalize the physical cue—confront the distortion (or fear) aboutthe physical cue.

3. Respond appropriately to cue.

Every eating experience is an opportunity tolearn about the body. For example, if forsome reason the patient did not eat enoughfood at a meal—did she get hungriersooner? (Usually, yes). Did she think aboutfood more often? (Usually, yes).

Or, if she ate beyond comfortablefullness, did she feel satisfied andsustained for a longer period of time?(Usually, yes). Were there fewer thoughtsabout food? (Usually, yes).

Phase 3: Indicators of Readiness forIntuitive Eating

While many patients would like to jumpinto Intuitive Eating, it is best to look forreadiness indicators before proceeding.Is the patient able to:

• Recognize that the eating disorder isabout something deeper—weight andeating are symptoms?

• Tolerate risk? As a person beginsto heal both physically andpsychologically, she is able to takeand tolerate risks with eating.

• Tolerate being uncomfortable?Trying new eating experiences canbe temporarily uncomfortable.

• Recognize (and manage) needs andfeelings? If an individual is not ableto identify her needs or cope withfeelings, she may continue to useeating disorder behaviors such asrestricting food, over-exercise, orbinge eating as coping strategies.

• Value Self-Care? Is she willing tofeed herself in the absence of hunger,

which may arise from ordinary lifestressors?

• Recognize vulnerability—such asbeing too hungry, too tired, toostressed and so forth?

Intuitive Eating Trial. In the beginning, itis best to explore a one or two-dayIntuitive Eating trial to determine if thepatient is truly ready to eat on the basis ofher biological cues. During this time, it ishelpful to explore these issues:

• Were you able to honor hunger/fullness cues in a timely manner?

• How did you respond to hunger cues?• How did you respond tofullness cues?

• Was there a part of you that wasthinking it was an opportunity for youto eat less? And, more importantly,did you act on that thought?

• If you were scared about an upcomingevent (such as eating dinner at arestaurant), did you compensate byeating less?

During this trial, a patient might discoverthat she doesn’t feel ready, and she mayopt to continue on her existing meal plan.It’s important to emphasize that this isnot failure. Rather, it usually reflects apatient’s desire to protect her recovery.It is important to move at an emotionallycomfortable pace (assuming she is eatingadequate calories). Moreover, it is stillpossible to move forward with otherIntuitive Eating principles within thisframework—such as working on permis-sion to eat any food. Patients often expressfeeling safer trying new food challengeswithin the framework of an eating plan.

There is no right or wrong way to proceed.The challenge is to create more eating

experiences that build self-trust. What doesthe patient need in order to feel safe?What types of foods and meals feelsatisfying and sustaining? What typesof foods would provide more socialconnectivity? For example, would theability to eat pizza without anxiety allowmore social interaction with her friends?

Exploring Unconditional Permissionto Eat. The ability to eat any food is animportant component of recovery andIntuitive Eating. Eating becomesemotionally neutral—without moraldilemma or shame—where the patientunderstands that one food, one meal, orone day of eating does not make or breakhealth or weight. When guilt is removedfrom eating, it is easier to be attuned to theneeds and experiences of the body.

Furthermore, habituation studies showthat the more a person is exposed to afood, eating becomes less distressful(Epstein, 2009).

A promising study from the Universityof Notre Dame applied the Intuitive Eatingprinciples to 30 women with diagnosedbinge eating disorder (Smitham, 2008).After eight, 90-minute, weekly sessions,binge episodes decreased significantly—80% of the women no longer met thediagnostic criteria for the disorder.

The Model: Integrating Intuitive Eatingfor Eating Disorder Recovery

Cook-Cottone (2006) developed theAttunement Representation Model toconceptualize the integration needed foran individual’s recovery from an eatingdisorder. This integration also aligns with

Figure 1: The Representational Self: Attunement and Expression

A Professional Journal of The Renfrew Center Foundation Page 14

Intuitive Eating. This model definesattunement as the dynamic integration ofa person’s inner and external worlds.A person with an eating disorder is skewedor mis-attuned toward the expectations ofothers (such as cultural expectations ofthinness). See figure 1.

Internal System. Ultimately, IntuitiveEating is an individual’s attunement withfood, mind and body. The Intuitive Eatingprinciples fall primarily within the internalsystem of the attunement model, whichconsists of a person’s thoughts, feelings,and physiology (biological sensations ofthe body).

ThoughtsPrinciple 1. Reject the Dieting

MentalityPrinciple 3. Make Peace with FoodPrinciple 4. Challenge the Food PolicePrinciple 8. RespectYour Body

FeelingsPrinciple 7. HonorYour Feelings

without Food

Physiology (Body)Principle 2. HonorYour HungerPrinciple 5. RespectYour FullnessPrinciple 6. Discover SatisfactionPrinciple 9. Exercise—

Feel the DifferencePrinciple 10. HonorYour Health

with Gentle Nutrition

The External System consists of family,communities, and culture. These externalinfluences include food traditions, culturalbeauty standards and public healthguidelines.

The last two principles of IntuitiveEating pertaining to exercise and nutrition,are components of both the inner andexternal systems and are excellentexamples of the dynamic integrationneeded to achieve authentic health.

For example, a person can integrateexercise recommendations for health whilebeing attuned to the experience of herbody. This type of physical activity is alsocalled “mindful exercise” (Calogero &Pedrotty, 2007) where exercise:

• Is used to rejuvenate the body,not exhaust or deplete it.

• Enhances the mind–body connectionand coordination, and does notconfuse or dysregulate it.

• Alleviates mental and physical stress,not contribute to and exacerbate stress.

• Provides genuine enjoyment andpleasure, not to provide pain and bepunitive.

The pursuit of exercise is about feelinggood, not about calories-burned or used asa penance for eating.

Similarly, health can be honored withgentle nutrition. For example, a familymay desire to eat locally-grown foods witha low carbon footprint. If a person is trulyinner-attuned, she can integrate this valuewithout resorting to an eating disorderbehavior or mind-set.

A person recovered from an eatingdisorder can eat within this dietaryframework, while paying attention tohunger, fullness, satisfaction and so forth.If, however, a person enters this realm toosoon, there is a risk for the new mindset tobe embraced as another rigid set of rules,fueling old eating disorder thinking andbehavior. Timing and readiness are the keys.

Ultimately, when a person recoversfrom an eating disorder, she trusts herinner body wisdom. She is at peace withher mind and body, and finally, enjoys thepleasures of eating without guilt or moraldecree.

References

Calogero, R. & Pedrotty, K. (2007).Daily practices for mindful exercise.In L. L’Abate, D. Embry, & M. Baggett(Eds.), Handbook of low-cost preventiveinterventions for physical and mentalhealth: Theory, research, and practice(pp.141-160). NewYork: Springer-Verlag.

Cook-Cottone, C. (2006).The attuned repre-sentation model for the primary preventionof eating disorders: an overview for schoolpsychologists. Psychology in the Schools,43 (2), 223-230.

Cook-Cottone, C.P., Beck, M., & Kane, L.(2008). Manualized-group treatment ofeating disorders: Attunement in mind, body,and relationship (AMBR). Journal forSpecialists in GroupWork, 33, 61-83.

Mathieu, J. (2009). What should you knowabout mindful and intuitive eating? Journalof the American Dietetic Association, 109(12), 1982-1987.

Scime, M., & Cook-Cottone, C.P. (2008).Primary prevention of eating disorders: Aconstructivist integration of mind and bodystrategies. International Journal of EatingDisorders, 41, 134-142.

Smitham, L.A. (2008). Evaluating anintuitive eating program for binge eatingdisorder: A bench-marking study[dissertation]. South Bend, IN: Universityof Notre Dame.

Tribole, E. (2009). Intuitive Eating: Can yoube healthy and eat anything? EatingDisorders Today.Winter: 10-11.

Tribole, E. & Resch, E. Intuitive Eating,2nd ed. (2003). NewYork: St. Martin’sPress.

Tylka T. (2006). Intuitive Eating assessmentscale. Journal of Counseling Psychology,53, 226-240.

Tylka, T. &Wilcox, J. (2006). Are IntuitiveEating and eating disorder symptomatologyopposite poles of the same construct?Journal of Counseling Psychology, 53 (4),474-485.

Evelyn Tribole, MS, RD,has written seven booksand co-authored IntuitiveEating. Ms. Tribolespecializes in eatingdisorders in NewportBeach, CA. She alsoteaches Intuitive Eating

PRO skills to health professionals.For more information, visitwww.EvelynTribole.com

Perspectives • Winter 2010 Page 15

Holding a 3 oz. Dixie cup with two almondsand an apple wedge inside, I glance aroundthe room.The meditation room is full witha curious excitement.With 21 spirituallyseeking overeaters, I’m attending a workshopon how to recover from holiday bloat.

“The morsels in your cup will becomea part of you,” the workshop leader says,softly guiding us into a conscious eatingexperience.

I’ve seen and heard the cliché “we arewhat we eat” hundreds of times before onbook jackets and lectures. In the Eating-n’-Motion® workshops I lead, I have said it.Now, the richness of Susan’s wordsshimmer in my body as a perennial truth.Eating literally makes food a part of me.This almond will become my skin, muscle,and bone very soon.

As I began to inhabit the subtlety of myexperience a realization struck me. We arewhat we eat, and it is in the ‘how of eating’that we encounter who we really are and theessence of our being human. To eat is toenter into an intimate partnership with life.In moments, this partnering will includemaking a vow.A vow of intention beyondlanguage itself.

Simply said, to eat is to live and not toeat is to die. At its deepest level to be born,to incarnate, is to be hungry and full.

“Eat as if it were a moving meditation,”Susan says. “Be aware of your hand as itbrings the almond up to your mouth.”

Sitting on oversized floor pillows, theatmosphere in our circle is full and plush.Slowing down my fast food style ofdevouring, each miniscule movement takeson a new significance. It’s as if the bend inmy elbow, the reach of my finger, thetouching of the almond, were my first andmy last.

“Remember, this is your mouth, yourhand, your body,” I tell myself. Unfasteningthe parched safety latch of my lips, I seatthe almond on my tongue. I can feel the …“Stop,” Susan tells everyone. Slamming onthe brakes, my upper lip already molded tomy almond’s rutted surface, sticks in adher-ence. Its dryness bonds to my skin, suckingout the remaining moisture like a papertowel dropped on top of a kitchen spill.

Reflexively licking across the adhesiveseal the almond falls onto my tongue. Likedriving with the emergency brake on,

tension between my impulse to chew andinhibit thicken into a muscular articulationof choice that embodies the hinge ofmy jaw.

Funny thing—mindfulness. Time beginsto change on you. A moment seems likeforever, which can be a delight or hell.“Okay, now bite and notice something new.”My bite splits the almond into halves. Theinvisible boundary defining othernesscracks under the shearing pressure of mydesire. Snap… a whiff of bitter almondignites an updraft at the back of my throatdrawing the almond’s aroma upward intomy nasal passages. My tongue follows thetrail in quick pursuit.

I need to swallow badly. It’s sort of likehaving to pee. “Don’t swallow just yet,”Susan tells us, with the knife-like precisionthat could separate light from darkness.She’s encouraging us to just sense ratherthan think or act. “What the hell,” myagitation shouts back at her in silence.“Let’s eat!”

“Mastery with emotional eating ismastery of the swallow,” Susan says. Now,that piece of wisdom is worth the price ofpatience. I like that, but give me a break…I want to swallow!

Sliding against the almond’s grainysmoothness changes into the feel of rawsandpaper. My cat, Zoë comes to mythoughts when she’s meticulously lickingmy thumb. How soft her tongue is in onedirection and pleasurably raspy in another.An interesting mixture of longing and frus-tration vice my belly into an all too familiarknot of self-deprivation that swells up intomy rib cage.

This exercise is taking forever andI’m pissed. It’s Susan’s fault. She’s socontrolling. So much for falling in love andtrying to impress the workshop leader withhow conscious I am. Married and divorcedall in three minutes. Talk about gulping!

I did my mindful eating bit. I get it,all right! So let’s eat. Get to the next stepalready! I want to gulp now!

My mind’s amperage is turned up sohigh I can’t shut off the sizzle. I’m not reallyhaving thoughts, but a formless kind ofrestlessness. I’ve experienced these feelingsother times when I have brought a quietingpresence to my every day ordinariness.Being this intimate with my mouth, rather

than losing myself in the object of mydesire—food, spice and everything nice, isnerve racking.

Mind scrambles to get back onlineagain. “Maybe it’s your gluttony of wantingmore Terry, or the nostalgic reverie ofalmond mush sliding down your esophagusin a victorious swallow. “Naa… It’s just adamn almond.” “Get real” mind’s second incommand back-up critic demands withharsh chastisement.

Being a good workshop participant, Iguide my attention back in a Zen kind ofway. Embedded in my frustration is awhisper of “just be with what is, feel sensa-tions as they arise.” I get distracted by theyoung guy’s toes across from me playingwith the soft green carpet.

Holding off on the ‘rush’ of gratificationthat a good ole quick gulp delivers,illumination explodes! Inherent in thepleasure of every mouthful lives its shadowside of loss. To have means to lose andtherefore, not have…which is to have it all.The Buddhist Heart Sutra on the nature ofimpermanence is in every chew. Crap,I just want to eat. I do not want realitywith a capital ‘R’ linked to pleasure andsatisfaction. I might as well binge if that’sgoing to be the case.

Reality is secretly sandwiched betweengluttony and deprivation. Here resides thedisillusionment of ‘forever more’ and myavoidance of limitation. Enjoyment that isinclusive of sorrow, satisfaction that holdsboth fullness and emptiness, is hard for eventhe most advanced eater to swallow.

Much of what I have mistaken as myrush-flush love for food and comfort hasbeen confused with my gastronomicstrategy to end all suffering—stuffingmyself silly. So much for the sanctityof hedonistic overindulgence! And to addinsult to incarnational injury, all thisrevelatory non-duality is another attempt tofind refuge from the erupting anxiety ofchange.What eater wants to feel loss inevery bite? Not the smartest of advertisingslogans. Reality is not exactly a big sellingticket at McDonald’s or during my primetime 11:30 PM refrigerator raids.

I’m tenser than ever now! The clock bythe window reads 2:00 PM. It’s been twominutes or more exactly, three and a halfchews into an almond since we started

Breathing UnderwaterTerry Nathanson, LCSW, LMT

A Professional Journal of The Renfrew Center Foundation Page 16

‘eating.’ I’m in some Sartre-esque diningroom experience sitting at a table with theBuddha and the devil. “Food is food,”Buddha says, compassionately smiling.“Just swallow and enjoy, there’s more wherethat came from,” says the devil.” Or was thatthe Buddha?

Swallow man, swallow already…saveyourself, some part of me yells from abovethe water line.You’re drowning. “Let meout” reverberates silently between mygritting teeth and tongue. Judgments punchat my soft palate hard. I can’t even tasteanymore. In fact, I am not sure I ever reallytasted. Flailing in terror, some part of megrabs onto my mind to make sense of thissenselessness. I am going under for thethird time.’’

“Everyone breathe,” Susan lovinglywhispers, from the shore-line of here andnow far away in the distance. “Separate outthe mashed almond from your saliva,” sheencourages the group. “Use your tongue topush the pulp to the side of your mouth andlet your self taste.”

My inner eye pivots in a quick one-eighty. Its fixation on the no-exit sign ofhopelessness releases with a sigh. Mymouth full with saliva is ready to burstthrough my lips any second now. I had noidea I was literally foaming at the mouth.

Muscular contractions have been pulsingin my throat in a struggle to neutralize mygag reflex. When my dentist waits too longin suctioning the basin of my throat duringdrilling a filling, I feel the same thing.This survival reflex has saved me fromswallowing a fate worse than an almondmany times before in my life.

“Swallow whenever you are ready,”

Susan gently suggests. “Whoa!” My terrordissolves immediately in the flush. It is as ifI woke up from a dream where I was facedown in a tub of water. Sitting up back intomy body, resuscitates myself and a longneeded “ahhhh” remedies my throat andchest in a bath of soothing vibration. This isa relief well beyond the sensuous ‘slide’ offinely masticated almonds making nice ontheir way down to my belly, thank you verymuch. Tectonic plates of being have shiftedunder the identity of who I thought I was asan eater. My embodied nature as animal,human and divine is unfolding quickly.

Sharing all this with Carol, one of theworkshop participants sitting next to me, mymouth dilates with excitement. A restrictedflow of saliva has been freed up from ahistory of having to swallow my aliveness.I had not realized how easy I was. Just alittle in-real-time connection and my mouthreaches high tide again. Surf’s up with anurgent undertow not to feel my urgency. Iwant to go to my default program which hasbeen to hide from my revelations, longingand transparent vulnerability and swallow—‘all gone’. I experiment with inhibiting mytendency to gulp a bit longer.

“Carol,” saliva seeping out of the leftcorner of my mouth, “I swallow my alive-ness so as not to be flooded with feeling.This is why I gulp my food before reallysavoring. It is happening right now.” Mytrue enjoyment and pleasure never breaksinto the surface tension of my awareness.Carol empathically nods. A ‘pop-up’memory suddenly emerges into myawareness. I grew up in fear of my motherswallowing me up whenever I excitedlyexpressed my aliveness, my individuality.

It’s as if she needed me more than I her.As I see Carol’s eyes tear up, I know I

am the one who has been swallowing myexcitement. I have been living in ‘once aupon a time,’ as if it were reality. “It’s likelearning to breath underwater,” I tell Carol,joy radiating through my face. “This is me.”She smiles and hugs me.

In my own element, I am breathingunderwater. Fifty years later, I am in myown experience, here and now. No one,snack or meal can take me from myselfexcept for me.

For over 25 years TerryNathanson, LCSW, LMThas helped clients witheating difficulties and self-nurturance. As an eatingcoach, Terry blendsGestalt, Internal FamilySystems, and eastern

contemplative traditions with establishedbody-mind approaches— all to supportclients in establishing their healthy relation-ship with food.

Founder of Eatingmatters of NewYork,Terry leads workshops at Renfrew’s annualconferences, the Omega Institute andKripaluYoga Center. Eating consultation,one-on-one sessions, and appetite re-training intensives, are available for profes-sionals.

If you or a loved one has an eating disorder, The Renfrew Center is the only treatment facility in the country with programming specifically geared toward observant Jewish women. All food is provided by a Glatt kosher caterer and religious practice is respected.

Renfrew’s Treatment Programs: • Intensive Outpatient Care • Day Treatment Program • Residential

For more information, call 1-800-RENFREW or visitwww.renfrewcenter.com

Ramaz Middle School114 East 85th StreetNew York, NY 10028

1-877-367-3383www.renfrew.org

Sunday, June 7, 2009 9:00 a.m. - 5:00 p.m.

A TREATMENT PROGRAM FOR

OBSERVANT JEWISH WOMEN

IN THE NEW YORK AREA

FOOD, BODY IMAGE, and EATING

DISORDERS in the JEWISH COMMUNITY

The Renfrew Center is pleased to announce:

Register for The Renfrew Center Foundation’s seminar:

Perspectives • Winter 2010 Page 17

Offering 4 CEs • 9:00am – 1:00pm

Friday,April 9, 2010 Philadelphia, PAFriday, May 7, 2010 Bethesda, MDWednesday, October 20, 2010 Boca Raton, FL

Featured Speaker:Adrienne Ressler, MA, LMSW, CEDSNational Training Director and Body Image ExpertThe Renfrew Center Foundation

The Renfrew Center Foundation is pleased to present a half-day seminarfor mental health professionals, educators, clergy and families addressingwomen’s body image issues and eating disorders within the Jewish community.

The Renfrew Center Foundation Presents:

FOOD, BODY IMAGE ANDEATING DISORDERS IN THEJEWISH COMMUNITY

For more information:visit www.renfrew.org or callDebbie Lucker at 1-877-367-3383.

The Renfrew CenterFoundation Presents

Online TrainingSeminars forProfessionals12:00 – 1:00 PM EST

CUTTING EDGE TREATMENTSFOR EATING DISORDERSPRESENTED BY: DOUG BUNNELL, PHDFRIDAY, MARCH 19, 2010

MEDICAL COMPLICATIONSOF EATING DISORDERSPRESENTED BY: FRANCI KRAMAN, MDFRIDAY, APRIL 16, 2010

BINGE EATING DISORDERANDWEIGHT LOSS SURGERYPRESENTED BY: SANDY ARIOLI, RN, LMHCFRIDAY, APRIL 23, 2010

EATING DISORDERS,MOOD DISORDERS, ANDPHARMACOLOGICAL INTERVENTIONSPRESENTED BY: SHAWN GERSMAN, MDMONDAY, MAY 3, 2010

THE RELATIONSHIP BETWEENTRAUMA AND EATING DISORDERSPRESENTED BY: ANGELA REDLAK-OLCESE, PSYDFRIDAY, MAY 21, 2010

THE USE OF DBT IN THETREATMENT OF EATING DISORDERSPRESENTED BY: GAYLE BROOKS, PHDFRIDAY, JUNE 4, 2010

COST: FREE

TO REGISTER ONLINE, PLEASE VISIT:WWW.RENFREW.ORG

FOR MORE INFORMATION OR ASSISTANCE, PLEASECALL LOREN HEYWOOD AT 1-877-367-3383 OREMAIL LHEYWOOD@RENFREWCENTER.COM

The Nation’s Leader in Eating DisordersTrainingPresents the 2010 Spring Seminar Series for ProfessionalsWe’re Bringing Our Expertise toYou

HUNGERS OF THE SOUL: SPIRITUALITY,HOPE,AND FORGIVENESSIN THETREATMENT OF EATING DISORDERSJennifer Nardozzi, PsyD

INSATIABLE HUNGERS: EATING DISORDERS,CHEMICAL DEPENDENCYAND DEPRESSION INWOMENAdrienne Ressler, MA, LMSW, CEDS

March 26 – Chapel Hill,NCApril 16 – Indianapolis, INApril 30 – Albany,NYMay 14 – Long Island,NYMay 21 – Cleveland,OHJune 4 – Boston,MA

9:00am – 4:00pm • Offering 6 CE Credits

For more information, visit www.renfrew.org or call Debbie Lucker at 1-877-367-3383.

19thTheNineteenthAnnualConference Update

Onbehalf of the 2009 Conference Committee, Iwould like to extend thanks to all of the speakers,attendees and staff for making Renfrew’s 19th

Annual Conference a great success. This year, we welcomedhundreds of professionals from all over the U.S., Canada,Australia, Italy, Israel and Brazil.

The Conference theme,The Art and Science of EatingDisorders Treatment, featured presentations on a widevariety of topics ranging from traditional and experientialtherapies to neuroscience and the link between mind, brainand body.Workshops addressed the role of the therapist andthe integration of various therapeutic approaches andevidence based treatments into the recovery process, as it hasbecome more essential than ever for clinicians to beembedded in many theoretical worlds.

Dr. Joan Borysenko delivered a personal, inspirationalKeynote which addressed the psychospiritual developmentof women during the major stages of the feminine lifecycle.Her presentation was described by many attendees asuplifting, empowering and thought-provoking. Dr.DanielSiegel, our Saturday Keynote speaker, examined well-beingthrough the lens of science.He clearly articulated complexmaterial in a fascinating, understandable manner, inter-weaving science and spirituality while validating the rela-tional work that takes place throughout treatment.Ourclosing Keynote Panel, moderated by Dr. Bill Davis, broughttogether seasoned clinicians - Dr. Kathryn Zerbe,Dr. JimLock and Carolyn Costin, for a discussion of treatment issuesfrom their different perspectives.The interactions among thepanelists and questions from the audience were enlighteningand provided practical answers to many of the challengesmost clinicians face with eating disorder clients and families.

Throughout the weekend, there were also numerous oppor-tunities for professionals to enjoy the camaraderie ofnetworking and reconnecting with colleagues, as well asattending special breakfasts and evening events.We greatlyappreciate those of you who participated with such enthu-siasm!

Next year,The Renfrew Center Foundation will celebrateits 20th Annual Conference for Professionals.We are greatlylooking forward to this milestone event.A preview of whatwe have planned can be found on PAGE 20.

This update includes photos from the conference as well as aform to order CDs if you were unable to attend or missedsome workshops.Many thanks again for making Conference2009 such a great success and we hope to see you nextNovember!

A Professional Journal of The Renfrew Center Foundation Page 18

“What I love most and carry withme from each conference is therejuvenation, the replenishment andthe sense of community with otherswho do this work.Thank you!”

Perspectives • Winter 2010 Page 19

“Great conference, great food,great colleagues.”

“This is the best conference I’veattended in my 10 years of practice.”

“It was a therapist’s heaven.”

THE RENFREW CENTER FOUNDATIONCELEBRATES ITS

20th ANNUAL CONFERENCE FOR PROFESSIONALS

Feminist Perspectives and Beyond:Honoring the Past, Embracing the Future

Philadelphia Airport MarriottNovember 12-14, 2010

To commemorate this milestone,Renfrew has planned three days of invited presentationsby outstanding leaders in the field.The Conference 2010 program will address significantaspects of eating disorders theory, treatment, prevention, and research.

KEYNOTE PRESENTATIONS

Gloria SteinemCraig Johnson, PhD and Michael Levine, PhD

Cynthia Bulik, PhD

TOPICS TO BE EXPLORED INCLUDE:

A Call for Proposals and Posters will resume in 2011.

For more information, please visit www.renfrew.orgor call Debbie Lucker at 1-877-367-3383.

A Professional Journal of The Renfrew Center Foundation Page 20

SAVE THE DATE!

• Traditional Therapeutic andComplementary Approaches

• Body Image• Treatment Issues• Co-morbid Conditions• Family & GroupWork

• Neuroscience/Attachment• The Therapeutic Alliance• Genetics• Diagnoses and Etiology• Integrating Evidence BasedGuidelines & New ResearchFindings into Treatment

AUDIO CD AND MP3 ORDER FORMThe 19th Annual Renfrew Center Foundation Conference

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�� PLEASE CHECK THE CDS YOUWISH TO ORDER

Perspectives • Winter 2010 Page 21

Thursday All Day Workshops

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FR7 Dagg & Little Fed Up: Get Fed! Family Eating Disorder Recipes $20

FR8 Feinson & Wyshogrod Reclaiming Inner Wisdom: Mindful Approaches… $20

FR9 Freizinger & Balz Managing the Chaos: Dialectical Behavior Therapy… $20

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FR12 Walsh Eating w/ Your Genes Off? Epigenetics & Anorexia Nervosa $20

Keynote Presentations

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A Professional Journal of The Renfrew Center Foundation Page 22Saturday Workshops

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SA5 Matz & Frankel The Diet Survivor’s Circle… $20

SA7 Feibish & Brendler A Model of Supervision… $20

SA8 Ice, Kraman & Wingate East Meets West: A Medical Approach… $20

SA9 Lock Family-Based Treatment of Adolescent Eating Disorders $20

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Perspectives • Winter 2010 Page 23

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� Treatment Scholarships � Training & Education� Area of Greatest Need � Research

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As a professional and educator working with individualsaffected by eating disorders, you are undoubtedly aware of thedevastation these illnesses cause to families and communities.

The Renfrew Center Foundation continues to fulfill our mission ofadvancing the education, prevention, research and treatment of eatingdisorders; however,we cannot do this without your support.

Your Donation Makes A Difference…• Tomanywomen who cannot afford adequate treatment.• To thousands of professionals who take part in ournationwide seminars and trainings.

• To the multitude of people who learn about the signs andsymptoms of eating disorders, while learning healthy waysto view their bodies and food.

• To the field of eating disorders through researching bestpractices to help people recover and sustain recovery.

An important source of our funding comes from professionals likeyou. Please consider a contribution that makes a difference!

Tax-deductible contributions can be sent to:The Renfrew Center FoundationAttn: Debbie Lucker475 Spring Lane, Philadelphia, PA 19128

Your Donation Makes a Difference

The Renfrew Center OpensNew Facility in Bethesda, MDand an Independent Affiliatein Guatemala.The Renfrew Center is pleased to announce the opening of anew site in Bethesda,Maryland and AKASA, an independentaffiliate in Guatemala,Central America.

Programming offers a comprehensive rangeof services including:• DayTreatment Program• Intensive Outpatient Program• GroupTherapy• Individual, Family, and CouplesTherapy• NutritionTherapy• Psychiatric Consultation

For more information, please call 1-800-RENFREWor visit our web site at www.renfrewcenter.com

The Renfrew Center is celebrating its25thAnniversary as the country’s firstresidential eating disorder treatment facility.Renfrew is the first and largest eating disorder treatmentnetwork in the country and has treated over 50,000 womenwith eating disorders.We provide a comprehensive range ofservices in PA, FL,NY,NJ,CT,NC,TN,TX,MD andGuatemala, an independent affiliate.

In 2010, Renfrew will be hosting a 25th Anniversarycelebration at each of our sites!

Florida - April 2010New Jersey - May 2010Philadelphia - June 2010Connecticut - September 2010NewYork - October 2010North Carolina - December 2010

Continued through 2011:Texas - February 2011Tennessee - March 2011Maryland - April 2011

We hope you will join us in celebration of this great milestone!

For more information, please call 1-800-RENFREWor visit our web site at www.renfrewcenter.com

The Renfrew Center of Marylandis located at 4719 Hampden Lane,Suite 100, Bethesda,MD 20814

AKASA is located in Guatemala,Central America.

NON-PROFIT ORGU.S. POSTAGE

PAIDTHE RENFREW

CENTER FOUNDATION

The Renfrew Center Foundation475 Spring LanePhiladelphia, PA 19128

1-877-367-3383www.renfrew.org

1-800-RENFREWwww.renfrewcenter.com

The opinions published in Perspectives do not necessarily reflect those of The Renfrew Center. Each author is entitled to his orher own opinion, and the purpose of Perspectives is to give him/her a forum in which to voice it.

L O C A T I O N S

NORTHEAST SITES

Philadelphia, Pennsylvania475 Spring LanePhiladelphia, PA 19128

Radnor, Pennsylvania320 King of Prussia Road2nd FloorRadnor, PA 19087

NewYork, NewYork11 East 36th Street2nd FloorNewYork, NY 10016

Ridgewood, New Jersey174 Union StreetRidgewood, NJ 07450

Wilton, Connecticut436 Danbury RoadWilton, CT 06897

Bethesda, Maryland4719 Hampden LaneSuite 100Bethesda, MD 20814

SOUTHEAST SITES

Coconut Creek, Florida7700 Renfrew LaneCoconut Creek, FL 33073

Charlotte, North Carolina6633 Fairview RoadCharlotte, NC 28210

Nashville, Tennessee1624 Westgate CircleSuite 100Brentwood, TN 37027

Dallas, Texas9400 North Central ExpresswaySuite 150Dallas, TX 75231

INTERNATIONAL

Guatemala, Central AmericaAKASA, Independent Affiliate